Public Health

Health Insurance for People w Pre-existing Conditions in Jeopardy Again

A main driver for passing and implementing the Affordable Care Act was to ensure that people with pre-existing health conditions could buy health insurance.  Prior to the ACA- people with pre-existing medical conditions like diabetes faced real challenges getting health insurance.

Indeed, one of the most consistently popular parts of the ACA are the provisions that help people get  coverage regardless of health status.  The ACA prevents health insurance companies from denying someone a policy because they have a preexisting condition (called the “guaranteed issue” requirement), refusing to cover services that people need to treat a pre-existing condition (called “preexisting condition exclusions”), or charging a higher premium based on a person’s health status (called the “community rating” provision).   

You can think of pre-existing conditions exclusions, guarantee issue, and community rating as the three legs of the ACA stool.  Despite these largely popular provisions, there are people that want to knock over the stool.  Back in February, 20 states (including Arizona) filed a lawsuit in Texas federal court seeking to invalidate the 3 legs of the stool: preexisting condition exclusions, community rating, and guaranteed issue.

This most recent legal attack argues that the removal of the individual mandate penalty by the most recent federal tax cut legislation makes the ACA unconstitutional (the US Supreme Court upheld the ACA several years ago, in part, because the tax penalty provision provided a statutory hook for the ACA to rest on).  The lawsuit argues that because the mandate is an essential feature of the ACA, the rest of the law must be struck down too.  If the lawsuit eventually succeeds these central provisions of the ACA would go away and an estimated 17 million people could become uninsured again.

During the Obama Administration, the federal government defended the ACA from lawsuits like these.  Those days are over.  A couple of months ago, the U.S. Department of Justice announced that they agree with the plaintiff States that the ACA’s individual mandate is unconstitutional. The administration urged the court to strike down the law’s guaranteed issue, preexisting condition exclusion, and community rating provisions.

Prior to the ACA, standards to protect people with preexisting conditions were primarily determined at the state level.  Most states including AZ had very limited protections. Before the ACA, many insurers maintained lists of up to 400 different conditions that disqualified applicants from insurance or resulted in higher premiums.  35% of people who tried to buy insurance on their own were either turned down by an insurer, charged a higher premium, or had a benefit excluded from coverage because of their preexisting health problem.

If the Federal courts (ultimately the US Supreme Court probably) rule in favor of the plaintiffs, States could still play as a regulator of insurance, as they could enact and enforce their own laws to protect residents from discrimination due to preexisting conditions.  In fact, several states already have their own laws to incorporate some or all of the ACA’s protections (Arizona does not). 

Oral arguments have been scheduled for next week in the Texas lawsuit. Arguments are scheduled to take place next Monday before Judge Reed O’Connor.  Whatever the Federal TX Court rules, the result will likely be appealed to the UA Appellate Court and eventually probably the US Supreme Court.

Conflicting Rulings on Voter Initiative "Strict Compliance Standard"

107 years ago, Arizona's founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.  Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

  • The Smoke Free Arizona Act;
  • The TRUST Commission for tobacco education and prevention;
  • First Things First;
  • Establishment and funding of the Area Health Education Center programs; and
  • Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty.

In 2017 the State Legislature passed and Ducey signed HB2244 which changed the citizen's initiative compliance standard from "substantial compliance" to "strict compliance" for putting initiatives on the ballot. This law made it easier to reject petitions if there are any errors on the document, making it more difficult to put measures on the ballot in the future that are good for public health.

Last week there were conflicting court rulings regarding whether the standard set in  HB2244 is constitutional.  Maricopa County Superior Court Judge James Smith ruled that the Strict Compliance standard imposed by HB2244 is not constitutional (this was a case related to the ballot measure to fund schools).  However, in the very same day, Maricopa County Superior Court Judge James Kiley reached the opposite conclusion (on the clean energy initiative). 

Last week’s conflicting rulings mean that the AZ Supreme Court will likely need to settle the matter (and soon).  The result will have a big impact on voter’s ability to put future measures to voters to improve public health.

Webinar: Complying with Arizona's Opioid Related Licensing Requirements

AzHHA Webinar: Creating an AZ Opioid Compliance Program to Meet Licensing Regulations

Keep current with the AZ changes related to opioid prescribing, ordering and administration requirements in the hospital and outpatient clinic settings. AzHHA recently released the Arizona Opioid Compliance Toolkits for Hospitals and Outpatient Clinics. On Tuesday, September 18th, Coppersmith Brockelman, LLC, will present a webinar to review the new legal requirements and recommendations for structuring an opioid compliance program. 

For more information and to register, click here.

Federal Policy Decisions Eroding Health Insurance Stability

It’s been a few weeks since I’ve written about what’s happening with the Affordable Care Act- and there’s been some recent action- so here goes.

First of all, there’s good evidence that stable health insurance coverage helps people get preventive and primary care services that improve outcomes and downstream healthcare spending.  The Affordable Care Act included several provisions that helps people get these kinds of preventive services.  One of the primary goals of the ACA was to create broad access to robust health insurance coverage through: 

  • Employer mandated coverage for large employers;
  • An mandate to be insured or face a tax penalty to encourage full participation;
  • Subsidies and out-of-pocket protections for purchasing in the individual federal marketplaces;
  • Guaranteed issue and community rating of premiums;
  • Expansion of Medicaid to low-income adults; and
  • Ten essential health benefits for all marketplace insurance sold on the individual federal marketplaces, which includes requirements to cover services for mental health, substance abuse, and reproductive health.

It’s been working.  In the last several years the percentage of uninsured working-age adults decreased from 20% in 2013 to 12% by 2016 (nationally).  It would have been an even bigger decrease if all states had expanded Medicaid.  This  coverage expansion has led to increased access to preventive services, higher rates of having a usual source of primary care and increased affordability of care. 

However, progress is now stalling because of policy changes that have been made by the President like:

Cost Sharing Reduction Payments Stopped

In October 2017, the President announced that he was ending cost-sharing reduction payments (a program that previously reimbursed health insurance companies for the out-of-pocket protections available to some individuals who purchased coverage on the individual marketplaces). This caused higher premium rates in the individual marketplaces this year. 

Short Term Health Plans

The President also issued Executive Order 13813, which expanded “association health plans” and short-term, limited duration insurance. These plans create parallel markets in which healthier individuals move to cheaper plans that offer barebones coverage, destabilizing the marketplace.

Last week HHS and the US Department of Treasury followed through on the EO and issued a final rule that will allow consumers to buy short-term health plans to provide coverage for up to 36 months. These plans don’t need to comply with ACA requirements like covering essential health benefits, pre-existing conditions or the requirement to sell to any consumer regardless of health status.

These plans will likely attract younger, healthier and drive them out of the risk pool, which will increase costs in the ACA compliant plans.  It’s estimated that about 600,000 Americans will enroll in these short-term health plans, increasing federal spending on marketplace subsidies by $200M in 2019 and $28B over ten years.

Individual Mandate Effectively Expiring

As part of the new federal tax law, the individual mandate tax penalties will be $0 starting on January 2019, which will further erode the goal of increasing coverage and stabilizing insurance markets. In July 2018, the Commonwealth Fund predicted that eliminating the tax penalty will result in at least 2.8 million fewer Americans with coverage.  The nonpartisan Congressional Budget Office estimates that the number of people with health insurance will decrease 4M by 2019 and 13M by 2027.   CMS also cut funding for the federally-facilitated Exchange Navigator Program which will also contribute to decreased enrollment rates.

Risk Adjustment Payments

CMS announced in July that it would freeze $10.4B in 2017 risk adjustment payments. Luckily CMS released a final rule a couple of weeks ago to reinstate payments, so that’s an additional destabilizing thing that thankfully won’t happen at least for now.

Everyone benefits from access to primary and preventive services (including behavioral and reproductive health services), specialty care, and culturally appropriate care. If the individual insurance market continues to destabilize or doesn’t include affordable plans that offer comprehensive services, consumers may face expensive and inaccessible healthcare options. 

Many of the decisions that the President has been making make that outcome more likely in my opinion.

Loneliness as a Public Health Threat

I was surprised to learn this week that loneliness raises the risk of premature death by up to 50 percent-that makes loneliness a public health hazard on the scale of smoking and alcohol. Yet many medical and public health professionals haven't heard about how many risks it poses.

Loneliness means that a person has a small support network and minimal interpersonal contact, and it becomes more common with age.  When a person’s children move or a spouse dies many people find it harder to engage in social activities. Seniors in rural areas are particularly susceptible. Geographic isolation and lack of public transportation combine to keep them alone.

Lack of human contact has serious physiological consequences. Studies show that without human contact our risk of functional decline increases as does our risk of mobility loss. The risk of clinical dementia goes up by 64%.   These health problems further isolate those suffering from social isolation, threatening a vicious cycle of physical, emotional, and psychological decline.

Better support access to existing services is a good start as an intervention.  For example, programs like Meals on Wheels can identify isolated seniors and connect them with resources to reduce loneliness. Other places like churches and city senior centers also serve as important community connectors and potential evaluation and intervention points for lonesome people.

Medicare could prioritize coverage for programs like SilverSneakers which keeps seniors active and creates opportunities for social connections through group exercise.  The Welcome to Medicare and annual Medicare exams could provide opportunities for screening and interventions.  

Medicare Advantage plans could cover benefits to address social isolation.  With an ROI analysis, interventions to reduce isolation could reducing health care costs (the triple aim) while improving outcomes. Developing a reliable tool to screen seniors for social isolation would help as well. 

There's Hope for More Valley Fever Research Funds

Representatives Kyrsten Sinema and David Schweikert introduced a bill last week that, if it passes, will increase the funding that’s available for valley fever research.  The bill supports new research and incentivizes the development of innovative treatments to fight the disease. The bill would:

  • Provide incentives to researchers working to find new treatments for Valley Fever;
  • Streamline the approval and review process for new treatments of the disease;
  • Direct HHS to conduct research on Valley Fever and sets up a Valley Fever Advisory Committee to oversee the work; and
  • Establish a grant program to facilitate Valley Fever research by universities, hospitals, and non-profits.

Valley fever (Coccidiomycosis) treatment research funds are extremely limited, in part, because it’s a regional illness (unique to the desert southwest).  If the entire country were susceptible to the illness, there would probably be more private research funds invested because there would be a large commercial market for a treatment. 

Basically, that’s why we need an investment of federal funds and policy, because the return on the research investment for valley fever isn’t adequate to recoup costs of developing a treatment because not enough people are susceptible to the illness (because it’s limited to the desert southwest).

CMS Position on Native American Exemptions from State Medicaid Work Requirements Complicates AZ Waiver Request

A 2015 AZ law requires AHCCCS to annually ask the CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility.  The work requirement waiver requests turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that they're receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

Late last year AHCCCS submitted their annual official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services including a requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development activities (with exceptions) and a requirement to bi-annually verify compliance with the requirements and any changes in family income.  CMS has not yet ruled on the AZ request.

One of the exempted groups in the waiver request is American Indians.  Starting Friday (when HB 2228 takes effect) the exemption of tribal members won’t just be an administrative decision, but one required by Arizona law.  That’s because HB 2228 requires AHCCCS to exempt tribal members from their work requirement waiver requests.  Here’s the exact statutory language:

36-2903.09.  Waivers; annual submittal; definitions

B.  SUBSECTION A OF THIS SECTION DOES NOT INCLUDE OR APPLY TO AMERICAN INDIANS OR ALASKA NATIVES WHO ARE ELIGIBLE FOR SERVICES UNDER THIS ARTICLE, THROUGH THE INDIAN HEALTH SERVICE OR THROUGH A TRIBAL OR URBAN INDIAN HEALTH PROGRAM PURSUANT TO THE INDIAN SELF-DETERMINATION AND EDUCATION ASSISTANCE ACT AND THE INDIAN HEALTH CARE IMPROVEMENT ACT.

However, a letter signed by CMS official Brian Neale suggests that CMS won’t be approving waiver requests that exempt tribal members.  In a letter to tribal members he writes, regarding exempting tribal members from state Medicaid eligibility work requirements “… Unfortunately, we are constrained by statute and are concerned that requiring states to exempt AI/ANs from work and community engagement requirements could raise civil rights issues.”

In a nutshell, (beginning Friday) Arizona law will require AHCCCS to exempt American Indians from their directed work requirement waiver request (they have already administratively elected to do so).  CMS is on record saying that they're constrained by statute and have civil rights concerns about allowing states to exempt American Indians from work requirement and reporting waivers. 

It stands to follow that CMS may very well deny Arizona’s request to exempt tribal members from work and reporting requirements despite our new law (36-2903.09 (B)). If that happens, there will surely be a legal review to determine exactly the intent of 36-2903.09 (B)

New Public Health Return on Investment Report

AzPHA member J. Mac McCullough, PhD, MPH, who serves as an Assistant Professor at Arizona State University and Health Economist at Maricopa County Department of Public Health was commissioned by AcademyHealth to write a research synthesis examining the return on investment for public health funding.

It’s a very nice and concise report.  It’s available online on the AcademyHealth website.  Here are some excerpts from the report

Federal, state, and local agencies spend approximately $250 per person per year on the public health system, whereas more than $10,000 is spent on health care per person per year. Public health spending has been falling as proportion of total health spending since approximately 2000 and falling in inflation-adjusted terms since the Great Recession. These declines have resulted in cuts to the public health workforce and to public health program portfolios.

While linking public health and health care spending to improved health outcomes can be tricky, the body of evidence supporting prevention is strong. For example, we know that investment in tobacco cessation can save $2-3 for every $1 invested and that childhood vaccinations can save $5-11 for every $1 invested.

One especially relevant set of studies utilized a unique dataset of public health department expenditures in California. Researchers used instrumental variables to show that a $10 increase in per capita spending led to a 0.6 percent increase in the proportion of the population in very good or excellent health4 and reduced all cause mortality by 9.1 per 100,000.23 Researchers monetized these estimates to determine that every $1 invested in public health in California resulted in $67 to $88 of benefits to society.24

a 2017 systematic review of international studies found that spending for individual public health interventions, services, or policies had a median ROI of $14.30 per $1 invested.