Category Archives: Medicaid

Medicaid denies nearly half of requests for hepatitis C drug

Hepatitis C virus

Hepatitis C virus

By Michelle Andrews

People with hepatitis C who sought prescriptions for highly effective but pricey new drugs were significantly more likely to get turned down if they had Medicaid coverage than if they were insured by Medicare or private commercial policies, a recent study found.

Researchers at the University of Pennsylvania Perelman School of Medicine analyzed the hepatitis C prescriptions from 2,342 patients in Maryland, Delaware, Pennsylvania and New Jersey that were submitted between November 2014 and April 2015 to a large specialty pharmacy that serves the region.

The drugs included Sovaldi, Harvoni and Viekira Pak, and others that are part of the treatment regimen. A 12-week course of treatment for one patient can reach more than $90,000. Continue reading


Enrollment Guide: Tips on how to shop for a marketplace lan


Shopping CartBy Mary Agnes Carey

Open enrollment for the health law’s 2016 marketplace plans begins Sunday, and federal officials caution consumers to check out premium prices because in many places they may be higher. But officials are planning to offer new features to make the process faster and smoother for consumers.

They can already do some window-shopping for plans on the federal marketplace,  A new feature that may help some customers is an online, out-of-pocket expense calculator on the website to help estimate how much they will pay in deductibles and co-payments in addition to the monthly premiums.

Answers to these and other questions:

  • I enrolled on last year. Do I have to do it again?
  • I want to buy health insurance but can’t afford it. What should I do?
  • What if I make too much money to qualify for Medicaid but still can’t afford to buy coverage?
  • What if I have health problems?
  • I get health coverage at work and want to keep my current plan. Can I do that?
  • I didn’t get health insurance in 2015. What is going to happen to me now?
  • I own a business. Will I have to buy health insurance for my workers?

Continue reading


Newly insured treasure Medicaid, but growing pains felt


By Sara Varney

SAN DIEGO — The Affordable Care Act unleashed a building boom of community health centers across the country. At a cost of $11 billion, more than 950 health centers have opened and thousands have expanded or modernized.

In San Diego, new clinics have popped up on school campuses and busy street corners. Cramped storefront clinics have been replaced with gleaming, three-story medical centers with family medicine, radiology and physical therapy on site. They are outfitted to care for new immigrants in dozens of languages from Spanish to Somali.

The community health centers are the country’s largest primary care system for low-income patients, now working to absorb a tsunami of new Medicaid enrollees.

At age 58, after several worrisome decades without health insurance, Lori Simpson is finally getting treatment for her dangerously high blood pressure, a serious thyroid disorder and, after years of double vision that had made it difficult for her to work and care for her grandchildren, surgery for her eyes.

“I have nine medications that I get every month, and mine comes to a little over two hundred dollars,” Simpson said. Prescription medications for her husband, a diabetic, cost $400 a month. “We don’t pay anything, it’s all covered. It’s just amazing.”

Simpson goes to the Family Health Centers of San Diego, which saw an increase of 24,000 patients, almost overnight, after the Medicaid expansion began in January 2014. Dr. Chris Gordon, the center’s assistant medical director, said it was a rush primary care clinics have been waiting for ever since President Barack Obama signed the health law in 2010.

“We’ve anticipated this for years and have been planning for it,” Gordon said. “We have capacity to take on patients. These are patients that haven’t had access before because they just didn’t have the financial means to get in. And now all of a sudden, they actually get to come in, get to spend time with somebody and get to feel like they’re heard.” Continue reading


From pills to pins: Oregon is changing how it deals with back pain

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Doris Keene (right) at Portland’s Quest Center for Integrative Health. (Photo by Kristian Foden-Vencil/Oregon Public Broadcasting)

By Kristian Foden-Vencil
Oregon Public Broadcasting

When Portland resident Doris Keene raised her four children, she walked everywhere and stayed active. But when she turned 59, she says, everything fell apart.

“My leg started bothering me. First it was my knees.” She ignored the pain, and thinks now it was it the sciatic nerve acting up, all along. “I just tried to deal with it,” Keene says.

But eventually, she went to a doctor who prescribed Vicodin and muscle relaxants. In 2012, about one in four Oregonians received an opioid prescription – more than 900,000 people. The state currently leads the nation in nonmedical use of opioids. And about a third of the hospitalizations related to drug abuse in Oregon are because of opioids.

Keene says the drugs helped her, but only to a degree. Continue reading


Happy 50th birthday, Medicare. Your patients are getting healthier


Photo: Courtesy of Ed g2s under Creative Commons license

The past 15 years have seen a marked drop in deaths and hospitalizations among Medicare patients — people 65 and older. Teasing out why is tricky, but it seems a good trend for the 50-year-old program.


Five challenges facing Medicaid at 50


By Phil Galewitz


President Lyndon B. Johnson signed the bill creating Medicare and Medicaid at the library of former President Harry Truman, who was in attendance, on July 30, 1965. (Photo courtesy of Truman Library)

A “sleeper” provision when Congress created Medicare in 1965 to cover health care for seniors, Medicaid now provides coverage to nearly 1 in 4 Americans, at an annual cost of more than $500 billion.

Today, it is the workhorse of the U.S. health system, covering nearly half of all births, one-third of children and two-thirds of people in nursing homes.

Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.

Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.

Though it provides a vital safety net, Medicaid faces five big challenges to providing good care and control costs into the future: Continue reading


Medicaid Expansion: a Question of Math and Politics


President Barack Obama has vowed to redouble his administration’s efforts to persuade all states to expand Medicaid. But if history is any indication, achieving that goal will take some time.

By Christine Vestal

Flag-map_of_Florida.svgTAMPA, Florida — With its ruling in King v. Burwell last month, the U.S. Supreme Court likely settled the question of whether President Barack Obama’s signature Affordable Care Act will survive.

Whether and when the health law will be fully implemented in all 50 states is a different question.

“With the King decision behind us, the drumbeats for Medicaid expansion are increasing,” said Matt Salo, executive director of the National Association of Medicaid Directors. “There is movement in every state. They’ll get there. Maybe not today and maybe not this year, but they’ll get there soon.”

200px-Flag-map_of_TexasThat’s the hope of health care industry groups and legions of consumer advocates. Major business organizations and local and county governments are also onboard. Following the high court’s decision, President Obama vowed to do all he can to persuade states to opt in before he leaves office in 18 months.

But in the mostly Southern and Midwestern states that have rejected expansion, opposition shows little sign of abating.  Continue reading


Doctors order fewer preventive services for Medicaid patients – study finds


Blue doctorMichelle Andrews

Gynecologists ordered fewer preventive services for women who were insured by Medicaid than for those with private coverage, a recent study found.

The study by researchers at the Urban Institute examined how office-based primary care practices provided five recommended preventive services over a five-year period.

The services were clinical breast exams, pelvic exams, mammograms, Pap tests and depression screening.

The study used data from the National Ambulatory Medical Care Survey, a federal health database of services provided by physicians in office-based settings.

It looked at 12,444 visits to primary care practitioners by privately insured women and 1,519 visits by women who were covered by Medicaid between 2006 and 2010.

That difference reflects the fact that the share of women who are privately insured is seven times larger than those on Medicaid, the researchers said. Pregnancy-related visits and visits to clinics were excluded from the analysis.

Overall, 26 percent of the visits by women with Medicaid included at least one of the five services, compared with 31 percent of the visits by privately insured women. Continue reading


A new focus on family caregivers


A younger man holds an elderly man's handBy Susan Milligan

Iraq war veteran Doug Mercer had been home in McAlester, Oklahoma, for just four days when he was in a motorcycle accident that left him broken and brain-damaged.

His wife Michelle became his caregiver after he left the hospital, but nobody there explained how to transport him safely.  A few weeks later, Michelle struggled as she tried to get Doug from the car to his wheelchair, breaking his leg.

“They’re sending you home, and you’re thinking, ‘What?’ Nobody instructs you, and says, ‘This is what’s coming home with you and how to use it,’” she said.

The Mercers’ story was a driving force behind an Oklahoma law that took effect in November that requires hospitals to train a designated family caregiver to tend to the medical needs of a released patient.

As many as 42 million Americans take care of a family member at any given time.

Since then, 12 more states (Arkansas, Colorado, Connecticut, Indiana, Mississippi, New Hampshire, New Jersey, New Mexico, Nevada, Oregon, Virginia and West Virginia) have approved similar laws. In Illinois and New York, legislation is awaiting the governor’s signature.

As many as 42 million Americans take care of a family member at any given time. Traditionally, family caregivers provide assistance with bathing, dressing and eating. They shop for groceries and manage finances.

But as the number of elderly Americans with chronic conditions has grown, family caregivers have taken on medical tasks once provided only in hospitals, nursing homes or by home care professionals.

In an AARP survey released in 2012, nearly half of family caregivers said they administered multiple medications, cared for wounds, prepared food for special diets, used monitors or operated specialized medical equipment. Continue reading


Connecting released inmates to health care


9638276289_550f033bb8_nBy Michael Ollove

Joe Calderon faced uncomfortably high odds of dying after his release from a California prison in 2010.

According to one study, his chances of dying within two weeks — especially from a drug overdose, heart disease, homicide or suicide — were nearly 13 times greater than for a person who had never been incarcerated.

Despite suffering from hypertension during his 17 years and three days of incarceration, Calderon was lucky. He stumbled onto a city of San Francisco program that paid for health services for ex-offenders, and he was directed to Transitions Clinic, which provides comprehensive primary care for former prisoners with chronic illnesses. The clinic saw to all his health needs in the months after his release.

An increasing number of states are striving to connect released prisoners like Calderon to health care programs on the outside. Frequently, that means enrolling them in Medicaid and scheduling appointments for medical services before they are released.

Some state programs — in Massachusetts and Connecticut, for example — provide help to all outgoing prisoners. Programs in some other states are more targeted. Those in Rhode Island and New York, for instance, focus on ex-offenders with HIV or AIDS.

Elsewhere, probation and parole are being used to encourage ex-offenders to adhere to certain treatments. Utah, for example, passed a measure this year that cuts probation time for former prisoners if they get treatment for mental illness or substance abuse.

The goal of these programs isn’t just to address the health needs of a notoriously unhealthy population, but to improve the likelihood they will succeed in society.

“We want to support them as much as possible to make sure they are productive and do not return to prison,” said Dr. Shira Shavit, executive director of Transitions. Continue reading


Adult dental coverage expanding slowly in Medicaid



By Christine Vestal

NEW YORK – At the Interfaith Dental Center in Crown Heights, Brooklyn, people with dental pain can walk into a ground floor office off Bedford Avenue and get treated without an appointment. They might have to wait in a packed waiting room. But if they’re in the door by 5 p.m., a dentist will see them.

The majority of Americans have to travel miles to see a dentist who takes their insurance, particularly if they’re covered by Medicaid. 

Residents in this low- to middle-income neighborhood likely don’t realize how lucky they are. The majority of Americans have to travel miles to see a dentist who takes their insurance, particularly if they’re covered by Medicaid. Many dental patients with private insurance cannot afford to pay their share of the bill.

Federal law requires state Medicaid programs to include dental care for children, and the Affordable Care Act extended that requirement to private insurers. But the federal health law did little for adults: While premium tax credits were made available to help low-income people purchase health insurance, the subsidies cannot be used to purchase dental coverage except as an add-on to health coverage. No new dental benefit requirements were included for adults covered by Medicaid.

“The ACA was a big flop when it comes to adult dental coverage,” said Dr. Jonathan Shenkin, vice president of the American Dental Association (ADA).


Even so, some states have stepped up coverage for at least some adults on Medicaid. Virginia added a dental benefit for pregnant women in March. Colorado introduced limited adult dental coverage for the first time last year. Also last year, California, Illinois, Massachusetts and South Carolina reinstated benefits that had been cut in the years since the recession began in 2007. Indiana began offering expanded adult dental benefits this year. Continue reading


A top-rated nursing home is hard to find in Texas, 10 other states


Natalie Anne Sealy's headshot.

Natalie Sealy (Photo courtesy of Billie Pender)

LOCKHART, Texas — The call from the nursing home came just before dawn, jolting Martha Sherwood awake.

During the night, fire ants had swarmed over her 85-year-old mother, injecting their stinging venom into Natalie Sealy’s face, arms, hands and chest.

“She was just lying there being eaten alive,” said daughter Billie Pender, who said she and her sister had repeatedly complained about a broken windowsill in their mother’s room at Parkview Nursing and Rehabilitation Center.

In 11 states, 40 percent or more of nursing homes get Medicare’s lowest two lowest rating.

The Sept. 2 attack devastated Sealy, a retired bank teller with dementia. “She went steadily downhill,” dying in late March, said Sherwood, who brought a lawsuit against the home.

Their mother had chosen the for-profit facility two years earlier because it was near her adult children. The family didn’t know that Parkview scored poorly on staffing and other quality measures.

This year, Medicare rates it one star out of a possible five stars — the lowest rating possible — on Nursing Home Compare, which was designed by the federal government to help consumers choose a long-term care facility.

The problem for Sealy’s family and residents of many parts of the country is they have few, if any, higher-rated options if they want their loved ones close by.

In 11 states, 40 percent or more of nursing homes get the two lowest ratings, according to an analysis by the Kaiser Family Foundation.  (Kaiser Health News is an editorially independent program of the foundation.)


Texas has the highest percentage of one-and two-star homes in the country: 51 percent of its nursing homes are rated “below average,” or “much below average,” on Nursing Home Compare, according to the analysis. Louisiana is close behind at 49 percent, with Oklahoma, Georgia and West Virginia tying for third at 46 percent. Continue reading