Category Archives: Medicaid

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

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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.)

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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

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Federal funds for charity care at risk in states that refuse to expand Medicaid

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Flag-map_of_Florida.svgBy Christine Vestal
KHN

The federal government is quietly warning states that failure to expand Medicaid under the Affordable Care Act could imperil billions in federal subsidies for hospitals and doctors who care for the poor.

In an April 14 letter to Florida Medicaid director Justin Senior, Vikki Wachino, acting director of the U.S. Centers for Medicare and Medicaid Services (CMS) wrote: “Uncompensated care pool funding should not pay for costs that would be covered in a Medicaid expansion.”

Federal money to support low-income clinics and hospitals is slated to decline under the Affordable Care Act as more people become insured.

Medicaid is the joint federal-state government health insurance program for the poor. Under the Affordable Care Act, states can choose to expand coverage to more people, with the federal government paying the entire costs of expansion through next year.

Florida has asked CMS to renew $1.3 billion in federal funding for its 2016 “low-income pool,” even though the state has rejected Medicaid expansion.

CMS maintains that any extension must take into account the more than 800,000 residents whose medical bills would be covered by Medicaid were the state to expand the program.

Photo courtesy of Darwinek via Wikimedia Commons CC Continue reading

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Paying Medicaid enrollees to get check ups, quit smoking and low weight: Will It pay off?

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wellness-incentive-570By Phil Galewitz
KHN

When Bruce Hodgins went to the doctor for a checkup in Sioux City, Iowa, he was asked to complete a lengthy survey to gauge his health risks.

In return for filling it out, he saved a $10 monthly premium for his Medicaid coverage.

In Las Cruces, N.M., Isabel Juarez had her eyes tested, her teeth cleaned and recorded how many steps she walked with a pedometer.

In exchange, she received a $100 gift card from Medicaid to help her buy health care products including mouthwash, vitamins, soap and toothpaste.

Taking a cue from workplace wellness programs, Iowa and New Mexico are among more than a dozen states offering incentives to Medicaid beneficiaries to get them to make healthier decisions — and potentially save money for the state-federal health insurance program for the poor.

The stakes are huge because Medicaid enrollees are more likely to engage in unhealthy practices, such as smoking, and are less likely to get preventive care, studies show. Continue reading

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Some states pay doctors more to treat Medicaid patients

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Blue doctorBy Michael Ollove
Stateline

Fifteen states are betting they can convince more doctors to accept the growing number of patients covered by Medicaid with a simple incentive: more money.

The Affordable Care Act gave states federal dollars to raise Medicaid reimbursement rates for primary care services—but only temporarily. The federal spigot ran dry on Jan. 1.

Fearing that lowering the rates would exacerbate the shortage of primary care doctors willing to accept patients on Medicaid, the 15 states are dipping into their own coffers to continue to pay the doctors more.

It seems to be working. Continue reading

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US proposes rule for providing mental health ‘parity’ in Medicaid program

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Photo courtesy of Sanja Gjenero

By Jenny Gold
KHN

A federal law that passed in 2008 was supposed to ensure that when patients had insurance benefits for mental health and addiction treatment, the coverage was on par with what they received for medical and surgical care.

But until now, the government had only spelled out how the law applied to commercial plans.

That changed Monday, when federal officials released a long-awaited rule proposing how the parity law should also protect low-income Americans insured through the government’s Medicaid managed care and the Children’s Health Insurance Program (CHIP) plans. The proposed regulation is similar to one released in November 2013 for private insurers.

“Whether private insurance, Medicaid, or CHIP, all Americans deserve access to quality mental health services and substance use disorder services,” said Vikki Wachino, acting director at the Center for Medicaid and CHIP Services.

Medicaid and CHIP programs are funded jointly by the federal and state governments.

Even if the state has carved out some benefits under a separate behavioral health plan, patients would be protected under the rule. Medicare patients are generally not affected by the regulation, nor are those in Medicaid fee-for-service plans .

But the rule does affect the majority of the 70 million people on Medicaid who are in managed care plans, and the 8 million children covered by CHIP plans.

Insurers, advocates and the general public will have a chance to comment on the proposed rule. The government will then release a final version.

Photo courtesy of Sanja Gjenero

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Wanting mental health treatment and not getting it

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Jigsaw puzzle with one piece to add

By Michael Ollove
Stateline

More than a half-million adults who said they wanted help with their serious mental conditions last year couldn’t get it because they lacked the resources and weren’t eligible for Medicaid to pay for treatment, a new study finds.

Those people — an estimated 568,886 adults ages 18 through 64 diagnosed with a serious mental illness, serious psychological stress or substance use disorder at the start of last year — lived in 24 states that didn’t expand Medicaid eligibility under the Affordable Care Act in 2014, according to a study published this week from the American Mental Health Counselors Association (AMHCA).

More than a half-million adults who said they wanted help with their serious mental conditions last year couldn’t get it.

In contrast, 351,506 adults with those same mental health problems got treatment paid for by Medicaid in the 26 states and the District of Columbia, which did expand coverage of the state-federal health insurance program to eligible adults living on low incomes.

The upshot, said Joel Miller, AMHCA’s executive director, is “the health of hundreds of thousands of people would be improved” if all states provided Medicaid coverage as they were given the option to under the Affordable Care Act (ACA).

Photo: Willi Heidelbach
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Rural hospitals, one of the cornerstones of small town life, face increasing pressure

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Farm with red barnBy Guy Gugliotta
KHN

MOUNT VERNON, Texas — Despite residents’ concerns and a continuing need for services, the 25-bed hospital that served this small East Texas town for more than 25 years closed its doors at the end of 2014, joining the ranks of dozens of other small rural hospitals that have been unable to weather the punishment of a changing national health care environment.

For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis. “I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”

Since 2010, 48 rural hospitals have closed, the majority in Southern states, and 283 are in trouble.

The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas along, 10 have changed. 

“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from the University of North Carolina, whose rural health research program studies national trends in rural health care. “But there are a lot of things going on.” Continue reading

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50 years later the US Older Americans Act limps along, relying on local and state agencies to provide services

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A younger man holds an elderly man's handBy Rita Beamish
Stateline

This year marks a half-century since Congress created the Older Americans Act, the major vehicle for delivering social and nutrition services to people over 60.

But there’s little to celebrate on the golden anniversary of the law that helps people age at home.

Federal funding hasn’t kept up with the skyrocketing number of America’s seniors, now the largest elderly population in history.

That’s left states and communities struggling to provide the in-home support, meals, case management and other nonmedical services that help seniors avoid more costly nursing home care and enrolling in taxpayer-funded Medicaid.   Continue reading

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States strive to keep Medicaid patients out of ERs

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Sign for an emergency room.By Michael Ollove
Stateline

Nearly half the states use higher copayments to dissuade Medicaid recipients from unnecessary visits to emergency rooms, where care is more costly.

These states require patients to make the payments, which are as high as $30 per visit in Oklahoma, when it is later determined that they did not experience a true medical emergency.

But at least one multistate study has found that charging higher copayments does not reduce emergency department (ED) use by Medicaid recipients.

One reason might be that copays are hard to enforce, since EDs are legally obligated to examine anyone who walks through the doors, whether or not they can pay.

ED doctors and others in health policy also criticize copays as potentially dangerous, since they may lead people to think twice about seeking emergency care when they really need it.

Washington state and some Medicaid managed care plans around the country are trying a different approach. Instead of using financial disincentives, they are trying to keep frequent users out of the emergency department (practitioners prefer the name “emergency department” to “emergency room”) by enrolling them in primary care practices, scheduling appointments for them and, in some cases, making sure they get to the doctor’s office on time. The hope is that giving people comprehensive health care will make many ED trips unnecessary.

Reliable data are still sparse, but the early signs are encouraging: Washington state reported that a year after implementing its program, emergency room visits by Medicaid beneficiaries had declined by nearly 10 percent. Among frequent ED users, the drop was slightly greater. Continue reading

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More states lean toward Medicaid expansion

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Indiana state flagBy Christine Vestal
Stateline

The federal government yesterday approved Indiana’s plan to expand Medicaid under the Affordable Care Act, increasing the number of expansion states to 28, plus the District of Columbia.

With enrollment starting Feb. 1, Indiana’s plan could add an estimated 350,000 low-income adults to the nearly 5 million expected to enroll in the 27 states that expanded Medicaid last year.

In accepting Indiana’s plan, the Obama administration demonstrated its determination to increase the number of expansion states, even if it means waiving traditional Medicaid rules.

For example, under Indiana’s plan, people with incomes above the federal poverty level ($11,670 for an individual) must contribute to a health savings account or be locked out of coverage for six months.

The penalty for not paying into a health savings account, which has never before been approved by the U.S. Department of Health and Human Services, reflects an important GOP health care tenet: People who receive Medicaid benefits should take personal responsibility for their care. Republican Gov. Mike Pence called his plan “the first-ever consumer-driven health care plan for a low-income population.”

FamiliesUSA

FamiliesUSA

Judith Solomon, health policy director at the Center on Budget and Policy Priorities, which advocates for low-income people, noted that Indiana’s plan is derived from a successful demonstration project that has been in effect since 2007, so its green light doesn’t necessarily apply to other states.

Under the Medicaid expansion that is part of the Affordable Care Act (ACA), the federal government pays the full price for covering newly eligible adults with incomes up to 138 percent of the federal poverty level ($16,105) through 2016 and then gradually lowers its share to 90 percent in 2020 and beyond. Continue reading

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High court considers if providers can sue states for higher Medicaid pay

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Top row (left to right): Associate Justice Sonia Sotomayor, Associate Justice Stephen G. Breyer, Associate Justice Samuel A. Alito, and Associate Justice Elena Kagan. Bottom row (left to right): Associate Justice Clarence Thomas, Associate Justice Antonin Scalia, Chief Justice John G. Roberts, Associate Justice Anthony Kennedy, and Associate Justice Ruth Bader Ginsburg.

Top row (left to right): Associate Justice Sonia Sotomayor, Associate Justice Stephen G. Breyer, Associate Justice Samuel A. Alito, and Associate Justice Elena Kagan. Bottom row (left to right): Associate Justice Clarence Thomas, Associate Justice Antonin Scalia, Chief Justice John G. Roberts, Associate Justice Anthony Kennedy, and Associate Justice Ruth Bader Ginsburg.

By Phil Galewitz
KHN

The U.S. Supreme Court heard arguments Tuesday in a case that could block hospitals, doctors — or anyone else — from suing states over inadequate payment rates for providers who participate in the Medicaid program for low-income Americans.

Many doctors avoid seeing Medicaid recipients, saying the program pays too little. That can lead to delays and difficulties in getting care for millions of poor people.

Federal law requires Medicaid, which covers 70 million people, to provide the same access to care as that given to people with private insurance. But many doctors avoid seeing Medicaid recipients, saying the program pays too little. That can lead to delays and difficulties in getting care for millions of poor people.

In Armstrong vs. Exceptional Child Center, several providers for developmentally disabled Medicaid patients sued the state of Idaho after officials failed to increase Medicaid payments as required under a formula approved by the federal government.

An appellate court upheld a judgment in favor of the providers last year, noting that Idaho had conceded that it held rates flat since 2006 for “purely budgetary reasons.”

The issue before the high court is whether the U.S. Constitution gives providers the right to sue the state to increase their pay. And the court appeared split on that issue based on their remarks Tuesday. Continue reading

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States gear up to help Medicaid enrollees beat addictions

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CocaineBy Chrisine Vestal
Stateline

Under the Affordable Care Act, millions of low-income adults last year became eligible for Medicaid and subsidized health insurance for the first time.

Now states face a huge challenge: how to deal with an onslaught of able-bodied, 18- to 64-year olds who haven’t seen a doctor in years.

“It took a lot of time and effort to enroll everyone, particularly those who were new to the system,” said Matt Salo, director of the National Association of Medicaid Directors. “The next big step, and the biggest unknown, is finding out exactly how this newly insured population will use the health care system.”

In addition to increasing the number of people with health insurance, the Affordable Care Act for the first time made coverage of addiction services mandatory for all insurers, including Medicaid.

Until now, the vast majority of Medicaid beneficiaries were pregnant women, young children, and disabled and elderly adults. Relatively few able-bodied adults without children qualified, so states did not set up their Medicaid programs to treat them.

The newly insured, most of them young adults, have different needs. Though not as sick as existing Medicaid beneficiaries, the newcomers are more likely than the general population to have undiagnosed and untreated chronic illnesses such as diabetes and heart disease.

The starkest difference between the new population and the old one, however, is that the new enrollees have much higher rates of drug and alcohol addiction and mental illness.

The number of Medicaid enrollees receiving addiction services is expected to skyrocket over the next two years.

Of the estimated 18 million adults potentially eligible for Medicaid in all 50 states, at least 2.5 million have substance use disorders. Of the 19 million uninsured adults with slightly higher incomes who are eligible for subsidized exchange insurance, an estimated 2.8 million struggle with substance abuse, according to the most recent national survey by the U.S. Substance Abuse and Mental Health Services Administration.

In addition to increasing the number of people with health insurance, the ACA for the first time made coverage of addiction services and other behavioral health disorders mandatory for all insurers, including Medicaid. As a result, the number of Medicaid enrollees receiving addiction services is expected to skyrocket over the next two years.

Although Medicaid and other state and federal programs historically have provided care for people with serious mental illness, coverage of addiction treatments has been spotty. Optional under Medicaid until now, coverage in most states was limited, typically just for pregnant women and adolescents.

“It’s the biggest change in a generation for addiction services,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors. “Comprehensive addiction programs didn’t exist in Medicaid until now.” Continue reading

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Supreme Court battle brewing over Medicaid fees

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Twenty-dollar bill in medicine bottleBy Phil Galewitz
KHN

PALM BEACH GARDENS, Fla. — Rita Gorenflo’s 7-year-old son Nathaniel was in severe pain from a sinus infection.

But since the boy was covered by Medicaid, she couldn’t immediately find a specialist willing to see him.  After days of calling, she was finally able to get Nathaniel an appointment nearly a week later near their South Florida home. That was in 2005.

Last month, ruling in a lawsuit brought by the state’s pediatricians and patient advocacy groups, a federal district judge in Miami determined Nathaniel’s wait was “unreasonable” and that Florida’s Medicaid program was failing him and nearly 2 million other children by not paying enough money to doctors and dentists to ensure the kids have adequate access to care.

The case is the latest effort to get federal judges to force states to increase Medicaid provider payment rates for the state and federal program that covers about 70 million low-income Americans.

The Florida case is the latest effort to get federal judges to force states to increase Medicaid provider payment rates for the state and federal program that covers about 70 million low-income Americans.

In the past two decades, similar cases have been filed in numerous states, including California, Illinois, Massachusetts, Oklahoma, Texas and the District of Columbia– with many resulting in higher pay.

But while providers and patient advocates nationwide hailed the Florida decision, they are deeply worried about a U.S. Supreme Court case  that they say could restrict their ability across the country to seek judicial relief from low Medicaid reimbursement rates.

The high court on Jan. 20 will hear a case from Idaho seeking to overturn a 2011 lower court order to increase payments to providers serving Medicaid enrollees with development disabilities. Continue reading

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Obesity Costs Evident at the State Level | Brookings Institution

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Nearly 14 percent of Washington state’s Medicaid and nearly 8 percent of its Medicare spending goes to treat conditions caused by obesity.

At the state-level, a substantial share —between 6 percent and 20 percent—of Medicaid spending goes to adult obesity-related expenditures. In 2006, Oregon (18.8 percent), Arizona (17.0 percent) and Colorado (16.2 percent) saw the highest shares, while Kansas (6.5 percent), Virginia (6.8 percent) and North Dakota (7.5 percent) devoted the smallest shares of Medicaid spending to obesity-related expenditures.

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On a state-by-state basis, Medicare spending due to obesity was substantial, too, with shares varying from 5.2 percent to 10.2 percent in 2004.

The highest percent of obesity-attributable spending was found in Ohio (10.2 percent), Michigan (10.0 percent) and West Virginia (9.9 percent), while the lowest was in Hawaii (5.2 percent), Arizona (6.2 percent), and New Mexico (6.6 percent).

via Obesity Costs Evident at the State Level | Brookings Institution.

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