Thursday, August 17, 2017
The federal right to try law's next stop is the House of Representatives. The article in Kaiser Health News, House Expected To Hold Hearings On ‘Right-To-Try’ Bill That Senator Tied To FDA Funding provides this background
The Senate quickly passed the bill that would allow dying patients access to experimental drugs after Sen. Ron Johnson (R-Wis.) had threatened to slow down consideration of a separate bill to renew the FDA’s fee-collection authority. In other drug industry news, the FDA is implementing new rules about hiring foreign scientists, industry tightens controls to keep out counterfeit drugs, cancer trials are low on patients and costs of old drugs rising quickly for Medicaid.
Although given priority by the Senate, the bill isn't expected to get the same treatment by the House. According to an article in Roll Call, ‘Right to Try’ Bill Could Face Slower Action in House if the House committee changes the bill from the Senate version, things will slow down. Here's a bit of an overview from the article:
Currently, when a patient seeks access to an experimental drug, his or her physician must work with the drug company, the FDA and an institutional review board that signs off on drug testing to approve the treatment’s use. When originally introduced in January, Johnson’s bill would have taken the FDA and other government entities out of that process. It would have let the states define “terminal illness,” potentially leading to dozens of different standards across the country about who would qualify for access. It also would have prevented the FDA from using outcomes associated with the experimental use when considering the drug’s application.
The new bill, instead of leaving the definition of terminal illness to the states, says that eligible patients should have a “life-threatening disease or condition” as defined by current federal law. It also gives the FDA the right to use outcome data if the administration determines that it is critical to assessing the drug’s safety — or if the drug company wants the outcomes used.
The drug companies would also have to provide the FDA with information about the experimental uses. Like the original bill, the new version shields companies against liability, but extends that protection to manufacturers who chose not to grant access to treatments. The bill would also limit the drugs that can be provided to those that have already completed the first phase of formal clinical trials, which are conducted to assess drug safety.
Monday, August 14, 2017
According to recent stories about Medicare observation status, poor elders may be harder hit by this than those with more affluence. Medicare’s Observation Care Policy More Likely To Affect Low-Income Seniors makes note of "[a] new study finds that low-income patients are more likely to be kept in the hospital under observation, and the higher out-of-pocket spending that accompanies not being officially admitted is a bigger burden for them." The study referenced is published in the American Journal of Medicine. The article's abstract explains:
Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Since low-income status is associated with increased hospital utilization, there is concern that such beneficiaries may be at increased risk for high utilization and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high utilization and high financial liability for observation care compared to higher-income beneficiaries.
A subscription is required to access the full article.
The ABA Journal this month has a short piece especially relevant today, August 14, 2017. Today is the 82nd anniversary of the signing of the Social Security Act in 1935. Frances Perkins is highlighted in the article as "The Woman Behind America's Social Safety Net."
By late 1934, Roosevelt was facing conservative resistance to his New Deal programs in Congress and the courts. Moreover, it would take years before those who had immediate needs would see any benefit from the social security [Secretary of Labor Frances] Perkins favored. Roosevelt confided to others that the timing might not be right for old-age insurance.
Perkins was furious and confronted him, arguing that the nation’s dire condition might provide the political opportunity for a bold initiative. When Roosevelt gave her a Christmas deadline, Perkins invited the committee to her home, placed a bottle of scotch on a parlor table, and told them they were not to leave until they had framed a legislative proposal....
Okay -- admit it -- how many of us first came to know the name of Frances Perkins in the movie Dirty Dancing?
Kaiser Health News recently ran a story about the end of life consultations now covered by Medicare. End-Of-Life Advice: More Than 500,000 Chat On Medicare’s Dime offers some interesting statistics on the number of consults. "In 2016, the first year health care providers were allowed to bill for the service, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News show." In fact, that number is almost double of what the AMA projected for 2016. Although those numbers are good news for the proponents of the law, when compared to the numbers of Medicare beneficiaries overall, the percentage is quite low.
[O]nly a fraction of eligible Medicare providers — and patients — have used the benefit, which pays about $86 for the first 30-minute office visit and about $75 for additional sessions.... Nationwide, slightly more than 1 percent of the more than 56 million Medicare beneficiaries enrolled at the end of 2016 received advance-care planning talks, according to calculations by health policy analysts at Duke University....
The article explores some explanations for these numbers, including lack of knowledge of the benefit by doctors and lingering concerns over the "death panels" controversy.
Thursday, August 10, 2017
The GAO has issued a report that examines various federal programs for low-income individuals. Federal Low-Income Programs: Eligibility and Benefits Differ for Selected Programs Due to Complex and Varied Rules offers the following findings
Six key federally funded programs for low-income people vary significantly with regard to who is eligible, how income is counted and the maximum income applicants may have to be eligible, and the benefits provided. In fiscal year 2015, the most current data available, the federal government spent nearly $540 billion on benefits for these six programs—the Earned Income Tax Credit (EITC), Medicaid, the Housing Choice Voucher program, Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), and Temporary Assistance for Needy Families (TANF). The target population for each of these programs differs, for example, people who are elderly or disabled or who have dependent children. Further, some programs have conditions for continued eligibility, such as participation in work activities under TANF. The six programs also vary in what income is and is not counted when determining an applicant's eligibility. For example, certain programs, such as SNAP, disregard a portion of earned income, while others do not. The maximum amount of income an applicant may have and still be eligible for benefits, which is determined for some programs at the federal level and for others at the state or local level, also differs significantly. As of December 2016, this amount ranged from $5,359 per month for one state's Medicaid program to $0 per month in one state for TANF cash assistance, for a single parent with two children. Benefit levels also differed across the six selected programs, with average monthly benefits for these programs ranging in fiscal year 2015 from $258 for SNAP to $626 for Housing Choice Vouchers, and four of the six programs adjust benefits annually.Legal, administrative, and financial constraints pose challenges to efforts to streamline varying eligibility rules for federal low-income programs, according to GAO's current and previous work. A key challenge is that the programs are authorized by different federal statutes enacted at different times in response to differing circumstances. Other laws, such as appropriations laws, can also have an impact on federal programs and their rules. As a result, streamlining eligibility rules would require changing many laws and coordination among a broad set of lawmakers and congressional committees. A further challenge is that a different federal agency or office administers each program GAO reviewed. For some of these programs, such as TANF, state governments also establish some program rules, making it more difficult to streamline rules at the federal level within or across these programs. Finally, financial constraints may also affect efforts to streamline program rules. For example, if rule changes raise the income eligibility limit in a program, more people may become eligible and that program's costs may increase. Despite these challenges, Congress, federal agencies, and states have taken some steps to streamline program administration and rules, such as by making greater use of data-sharing where permitted by federal law and aligning programs' applications and eligibility determination processes. For example, SSI recipients in most states are automatically eligible for Medicaid, and GAO previously reported that some states have integrated the SNAP eligibility process with other low-income programs, such as through combined applications and common eligibility workers.
Tuesday, August 8, 2017
Recently the U.S. Senate passed S 178, the Elder Abuse Prevention and Prosecution Act which is "[t]o prevent elder abuse and exploitation and improve the justice system’s response to victims in elder abuse and exploitation cases."
Title I is "Supporting Federal Cases Involving Elder Justice", Title II is "Improved Data Collection & Federal Coordination", Title III covers enhanced services to victims of elder abuse, Title IV, the "Robert Matava Elder Abuse Prosecution Act of 2017", includes enhanced penalities for those email & telemarketing schemes targeting elders, as well as interstate initiaties and state training & technical assistance.
In Title V, Miscellaneous, there are sections that deal with GAO reports, "[c]ourt-appointed guardianship oversight activities under the Elder Justice Act...," outreach to both state and local law enforcement and a requirement that the AG "publish model power of attorney legislation for the purpose of preventing elder abuse" (section 504) and "publish best practices for improving guardianship proceedings and model legislation relating to guardianship proceedings for the purpose of preventing elder abuse."
Sunday, August 6, 2017
Mark your calendars for August 16, 2017 at 2:00 p.m. edt for a free webinar from Justice in Aging on In-Kind Support & Maintenance (ISM). Here's a description of the webinar:
Why do many clients receiving Supplemental Security Income (SSI) benefits only receive $490 each month instead of $735, and what can we do about it? In many cases, the reason is “in-kind support and maintenance” (ISM). A person who receives shelter and food from a friend or family member they live with is receiving in-kind support and maintenance. The Social Security Administration (SSA) counts that support as income and lowers their benefit. The ISM rule is unique to the SSI program, and causes a lot of confusion for recipients, advocates, and SSA. This free webinar, In-Kind Support and Maintenance, will explore the ins and outs of ISM, provide examples of how the rule works, and offer strategies for dealing with the rule. As SSI is a means-tested program, applicants and recipients must meet several financial eligibility criteria on an ongoing basis. The income and resources rules, including “in-kind support and maintenance,” are particularly complicated. These rules can cause significant hardship for low-income people trying to survive on SSI. Giving advocates the tools to successfully navigate the rules on behalf of their clients can make a big difference. The recipient in the example above could have an additional $245 per month for necessities like health care expenses, household expenses, transportation, and other basic needs.
To register for this webinar, click here.
Saturday, August 5, 2017
Justice in Aging is offering a free webinar on Tuesday August 8, 2017 at 2:00 p.m. edt on Bankruptcy Protections for Older Consumers. Here's the description of the webinar:
An increasing number of older consumers are struggling with unmanageable debt. Debt collectors are using aggressive tactics to pursue older adults with limited resources, making it critically important for legal services attorneys to understand protections that may help their clients. Bankruptcy may help older consumers eliminate debt and preserve income needed to pay rent, buy food, and keep the lights on. This free webinar, Bankruptcy Protections for Older Consumers, outlines the issues facing older consumers and offers strategies to address the challenges. This session will highlight the various protections available and alternatives to filing for bankruptcy.
Click here to register for this webinar.
Friday, July 28, 2017
The GAO has issued a new report regarding the FDA's right to try approach to experimental drugs. Investigational New Drugs: FDA Has Taken Steps to Improve the Expanded Access Program but Should Further Clarify How Adverse Events Data Are Used reviews the FDA's increased access to experimental drugs. Here's the findings from the report:
Under the Food and Drug Administration’s (FDA) expanded access program, patients with serious or life threatening ailments and no other comparable medical options can obtain access to investigational drugs outside of a clinical trial. Expanded access requests must be submitted to FDA but manufacturers must also grant permission for patients to access their investigational drugs. Of the nearly 5,800 expanded access requests that were submitted to FDA from fiscal year 2012 through 2015, FDA allowed 99 percent to proceed. Almost 96 percent of these requests were for single patients (either emergency or non-emergency). FDA’s review process for expanded access requests is designed such that all requests are either allowed or not allowed to proceed within 30 days of receiving each request. FDA typically responded to emergency single-patient requests within hours and other types of requests within the allotted 30 days.
FDA and other stakeholders, including a non-profit organization and a drug manufacturer, have taken steps to improve the expanded access process and patient access to drugs... Some states have also enacted "Right-to-Try" laws to facilitate patient access to investigational drugs. These laws provide liability and licensing protections for manufacturers and providers under state law if an adverse event—such as an adverse reaction to the drug—occurs with patients who were allowed access to investigational drugs. However, some stakeholders GAO interviewed cited concerns that these laws may not help patients access drugs, in part because they do not compel a manufacturer to provide access.
Manufacturers sponsoring clinical trials must submit safety reports to FDA that include adverse events data resulting from clinical trials and any expanded access use, to be used in assessing the safety of a drug within the drug approval process... Further, some of the manufacturers told GAO the guidance was unclear. These manufacturers noted that the lack of clear information can influence their decision whether to give patients access to their drugs because of their concerns that an adverse event will result in FDA placing a clinical hold on their drug, which could delay its development. This could impact FDA’s goal of facilitating expanded access to drugs for treatment use by patients with serious or life-threatening diseases or conditions, when appropriate.
Monday, July 24, 2017
Checking yourself out of the hospital, rather than being discharged, is known as DAMA (discharge against medical advice). The New York Times ran an article about the challenges in deciding to leave the hospital. The Patient Wants to Leave. The Hospital Says ‘No Way.’ references a recent study that illustrates the issues that may occur for elders who want to leave the hospital. "Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges." The article also discusses why folks choose to leave, for example, they feel better, they are worried about money, or they're afraid. The article also discusses the arguments against the DAMA and some confusion about the impact of DAMA on subsequent care. The abstract of the article, Discharge Against Medical Advice of Elderly Inpatients in the United States, elaborates "[d]ischarge against medical advice (DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on DAMA in this subgroup... Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups..." To order the article, click here.
Friday, July 21, 2017
In the latest chapter of an ongoing dispute between a specialized care facility, Melmark, Inc., and the older parents of a disabled adult son, Pennsylvania's intermediate Superior Court of Appeals has ruled in favor of the parents.
The July 19, 2017 appellate decision in Melmark v. Schutt is based on choice of law principles, analyzing whether New Jersey's more limited filial support law or Pennsylvania's broader filial law controlled. If applied, New Jersey law "would shield the [parents] from financial responsibility for [their son's] care because they are over age 55 and Alex is no longer a minor." By contrast, "Pennsylvania's filial support law...would provide no age-based exception to parental responsibility to pay for care rendered to an indigent adult child."
The parents and the son were all, as stipulated to the court, residents of New Jersey. New Jersey public funding paid from the son's specialized care needs at Melmark's Pennsylvania facility for some 11 years. However, when, as part of a "bring our children home" program, New Jersey cut the funding for cross-border placements, the parents, age 70 and 71 year old, opposed return of their 31-year old son, arguing lack of an appropriate placement. Eventually Melmark returned their son to New Jersey against the parents' wishes, with an outstanding bill for unpaid care totaling more than $205,000, incurred over his final 14 months at Melmark.
Both the Pennsylvania trial and appellate courts ruled against the facility, concluding that "the New Jersey statutory scheme reflects a legislative purpose to protect its elderly parents from financial liability associated with the provision of care for their public assistance-eligible indigent children under the present circumstances." The courts rejected application of Pennsylvania's law as controlling.
This is a tough case, with hard-line positions on the law staked out by both sides. One cannot expect facilities to provide quality care for free. On the other side, one can empathize with families who face limited local care choices and huge costs.
Ultimately, I anticipate these kinds of cross-border "family care and cost" disputes becoming more common in the future for care-dependent family members, as the impact of federal funding cuts trickle down to states with uneven resources of their own. Some of these problems won't see the courtroom, as facilities will likely resist any out-of-state placement where payment is not guaranteed by family members, old or young.
July 21, 2017 in Consumer Information, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Housing, Medicaid, Social Security, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Wednesday, July 19, 2017
Governing ran a recent story about how states will pay for in-home care for their residents who are elders. As Demand for At-Home Care Grows, States Debate How to Pay for It considers that aging Boomers may not want to reside in nursing homes and if they stay at home, they will need care at home. With a likely greater demand for inhome care, how will it be delivered and who will pay?
[F]iguring out how to pay for more home-based care is mostly left up to the states. Medicaid is the primary payer for home- and community-based care, although states can decide whether or not they’ll offer the coverage. All 50 states and the District of Columbia do have home- and community-based programs of some type, but most states have waiting lists for their programs. Meanwhile, 59 percent of Medicaid funding goes to nursing homes, where about half of those in long-term care receive their services. “Nursing home institutions are a powerful player in the health-care setting, so there’s long been political pressure to not pay for more home health care,” says [Kevin] Prindiville [, executive director of Justice in Aging].
The article highlights California and Washington state, at opposite ends of the spectrum in handling this issue. Waivers may help, or shifting money through legislation that gives flexibility.
Tuesday, July 18, 2017
I read this article last week in the New York Times (also published by the Kaiser Health News), the topic of which is something we should consider seriously. Poor Patient Care at Many Nursing Homes Despite Stricter Oversight discusses Medicare's Special Focus status.
While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to an analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.
The article highlights some individuals' experiences, with the basis of the article concerning the Special Focus program.
Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. The Centers for Medicare and Medicaid Services, or C.M.S., assign each state a set number of slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.
More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts. This year, the $2.6 million budget allows only 88 nursing homes to receive the designation, though regulators identified 435 as warranting scrutiny.
The article also discusses lapses by those facilities once on the watch list, how a facility earns its way off the watch list and how long it typically takes to do so and the staffing ratios in such facilities.
Background information about the special focus initiative can be found on the CMS website. You can find the list of special focus facilities on CMS website. For example, here is the one published in June of 2017.
Monday, July 17, 2017
The Medicare Trustees have also released their annual report on the health of Medicare J Medicare offers some helpful information about how to read the report
The Trustees Report is a detailed, lengthy document, containing a substantial amount of information on the past and estimated future financial operations of the Hospital Insurance and Supplementary Medical Insurance Trust Funds (see the links in the Downloads section below). We recommend that readers begin with the "Overview" section of the report. This section is fairly short, is written in "plain English," and summarizes all the key information concerning the expected financial outlook for Medicare. Substantial additional material is available in the later sections for those wishing to delve more deeply into the actuarial projections.
The report is downloadable as a pdf here. This report runs 263 pages (just a tiny bit shorter than the one from the SSA Trustees). Again, what do we want to know? We want to know whether Medicare is on sound financial footing. So let's get right to the bottom line (or pages 40-42). Here are the relevant portions of the conclusion in Section II
Total Medicare expenditures were $679 billion in 2016, and the Board projects that they will increase in most future years at a somewhat faster pace than either aggregate workers’ earnings or the economy overall. The faster increase is primarily due to the number of beneficiaries increasing more rapidly than the number of workers, coupled with a continued increase in the volume and intensity of services delivered. Based on the intermediate set of assumptions under current law, expenditures as a percentage of GDP would increase from the current 3.6 percent to a projected 5.9 percent by 2091.
The HI trust fund fails to meet the Board of Trustees’ short-range test of financial adequacy. In addition, as in past reports, the HI trust fund fails to meet the Trustees’ long-range test of close actuarial balance.
HI experienced deficits from 2008 through 2015, but annual surpluses are expected from 2016 through 2022 before deficits return for the remainder of the 75-year projection period. The projected trust fund depletion date is 2029, one year later than estimated in last year’s report. Actual HI expenditures in 2016 were slightly lower than the previous estimate. The projections are lower throughout the short-range period due to lower utilization and provider update assumptions. HI taxable payroll in 2016 was slightly higher than previously projected, and projections for HI tax income are lower after 2017 due to slower real-wage growth assumptions.
The HI actuarial deficit in this year’s report is 0.64 percent of taxable payroll, down from 0.73 percent in last year’s report. This result is due primarily to lower-than-estimated spending in 2016 and lower projected inpatient hospital utilization.
The financial outlook for SMI is fundamentally different than for HI due to the statutory differences in the methods of financing for these two components of Medicare. The Trustees project that both the Part B and Part D accounts of the SMI trust fund will remain in financial balance for all future years because beneficiary premiums and general revenue transfers are assumed to be set at a level to meet expected costs each year. However, SMI costs are projected to increase significantly as a share of GDP over the next 75 years, from 2.1 percent to 3.7 percent under current law. The projected Part B costs in this report are slightly higher over the short-range and long-range periods than the comparable projections in the previous report due to higher-than-expected actual spending for outpatient hospital services and physician-administered drugs in 2016 and a methodological change resulting in higher drug spending for patients with end-stage renal disease. The Part D short-range and long-range projections are lower than in past years’ reports, largely due to the increase in drug manufacturer rebates and lower utilization of hepatitis C drugs.
The financial projections shown for the Medicare program in this report reflect substantial, but very uncertain, cost savings deriving from provisions of the ACA and MACRA that lower increases in Medicare payment rates to most categories of health care providers. Without fundamental change in the current delivery system, these adjustments would probably not be viable indefinitely.
* * *
Policy makers should determine effective solutions to the long-range HI financial imbalance. Even assuming that the provider payment rates will be adequate, the HI program does not meet either the Trustees’ short-range test of financial adequacy or long-range test of close actuarial balance. HI revenues would cover only 88 percent of estimated expenditures in 2029 and 81 percent in 2050. By the end of the 75-year projection period, HI revenues could pay 88 percent of HI costs. Policy makers should also consider the likelihood that the price adjustments in current law may prove difficult to adhere to fully and may require even more changes to address the financial imbalance.
The projections in this year’s report continue to demonstrate the need for timely and effective action to address Medicare’s remaining financial challenges—including the projected depletion of the HI trust fund, this fund’s long-range financial imbalance, and the rapid growth in Medicare expenditures. Furthermore, if the growth in Medicare costs is comparable to growth under the illustrative alternative projections, then these further policy reforms will have to address much larger financial challenges than those assumed under current law. The Board of Trustees believes that solutions can and must be found to ensure the financial integrity of HI in the short and long term and to reduce the rate of growth in Medicare costs through viable means. Consideration of such reforms should not be delayed. The sooner the solutions are enacted, the more flexible and gradual they can be. Moreover, the early introduction of reforms increases the time available for affected individuals and organizations—including health care providers, beneficiaries, and taxpayers—to adjust their expectations and behavior. The Board recommends that Congress and the executive branch work closely together with a sense of urgency to address these challenges.
The SSA Trustees released the 2017 annual report on July 13, 2017. You can download the 269 page report as a pdf here or you can contact the Office of the Chief Actuary for a hard cc of the report. There is a lot of information in this report, but of course, what everyone wants to know is whether Social Security is running out of money. Section II, the Highlights, offers this conclusion
Under the intermediate assumptions, DI Trust Fund asset reserves are projected to become depleted in 2028, at which time continuing income to the DI Trust Fund would be sufficient to pay 93 percent of DI scheduled benefits. Therefore, legislative action is needed to address the DI program’s financial imbalance. The OASI Trust Fund reserves are projected to become depleted in 2035, at which time OASI income would be sufficient to pay 75 percent of OASI scheduled benefits.
The Trustees also project that annual cost for the OASDI program will exceed non-interest income throughout the projection period, and will exceed total income beginning in 2022 under the intermediate assumptions. The projected hypothetical combined OASI and DI Trust Fund asset reserves increase through 2021, begin to decline in 2022, and become depleted and unable to pay scheduled benefits in full on a timely basis in 2034. At the time of depletion of these combined reserves, continuing income to the combined trust funds would be sufficient to pay 77 percent of scheduled benefits. Lawmakers have a broad continuum of policy options that would close or reduce Social Security's long-term financing shortfall. Cost estimates for many such policy options are available at www.ssa.gov/OACT/solvency/provisions/.
The Trustees recommend that lawmakers address the projected trust fund shortfalls in a timely way in order to phase in necessary changes gradually and give workers and beneficiaries time to adjust to them. Implementing changes sooner rather than later would allow more generations to share in the needed revenue increases or reductions in scheduled benefits and could preserve more trust fund reserves to help finance future benefits. Social Security will play a critical role in the lives of 62 million beneficiaries and 173 million covered workers and their families in 2017. With informed discussion, creative thinking, and timely legislative action, Social Security can continue to protect future generations.
Friday, July 14, 2017
Justice in Aging has released a new issue brief for July about Medicare Savings Programs (MSP). Proposed Cuts to Medicaid Put Medicare Savings Programs At Risk explains the importance of the MSP for many Medicare beneficiaries, including paying their premiums. If the MSP program were cut or eliminated, many beneficiaries may no longer be able to afford Medicare.
Many low-income older adults are only able to participate in Medicare because Medicare Savings Programs help with their Medicare premiums, deductibles and co-pays. These critically important programs reach over 7 million people with Medicare, including 1.7 million older adults who are too poor to be able to afford Medicare but do not qualify for other Medicaid programs.1 With $772 billion in Medicaid cuts, the Better Care Reconciliation Act now being considered in the Senate could knock many older adults and people with disabilities off these programs, making Medicare unaffordable. As a result, those with the greatest needs will lose access to Medicare benefits because they will be unable to shoulder Medicare costs.
The brief explains QMBs, SLMBs, and QIs. It also explains the relationship between MSP and "Extra Help". Regardless of the Senate vote (maybe this week) on repeal and replace, the information in the brief about MSP and the other programs is really helpful. Check it out!
Sunday, July 9, 2017
Medicaid has been in the news frequently of late, as Congress debates the repeal of the Affordable Care Act. Kaiser Family Foundation released a new infographic on the relationship of Medicaid and veterans. Medicaid’s Role in Covering Veterans explains how Medicaid works as a safety net for veterans, helps with coverage for vets with complex medical issues, and provides federal matching funds (which may be affected by the repeal of the ACA). The infographic provides demographic data, lists the conditions of veterans (by percentages) on Medicaid and explains what would happen if Medicaid funding were reduced.
Thursday, June 29, 2017
The National Council on Aging (NCOA) posted a story on its blog explaining per capita caps and the impact on elders. Straight Talk for Seniors®: How Medicaid Caps Would Impact Seniors explains how Medicaid per capita caps would work.
Medicaid is funded jointly by the federal government and the states. Today, the federal government gives states matching funds to cover a percentage of their actual Medicaid costs. This keeps Medicaid affordable for states.
Under per capita caps, the federal government would limit, or cap, its contribution to the states based on a preset formula. This means states would be left paying the true cost of care for people in need. Many predict that states would face severe funding gaps and have to cut back on services to make up the difference.
If this is implemented, 5 states in particular would be hit hard as far as home and community based services funding, including my state of Florida. Those 5 states, besides Florida, are Alaska, Arizona, Georgia, and Nevada. The impact can be severe, as the article notes:
Medicaid per capita caps would hurt seniors in all states, but some states would fare worse than others. Here’s why.
First, the caps would be set based on each state’s 2016 Medicaid costs. This means states that were efficient and kept their costs low that year will be locked into a lower federal contribution. North Carolina, California, Nevada, Georgia, and Florida are examples of states that fall into this category.
Second, the caps would not adjust for an aging population. This means states whose 65+ population is growing faster than the national average will be locked into a smaller federal contribution that will not keep pace with growing costs. In fact, the caps would begin when baby boomers start turning 80. People aged 85+ are more likely to need long-term services and supports, and the cost of their care is 2.5 times more than people aged 65-74.
Monday, June 26, 2017
This week is a big one for the Senate as they consider the Republican version of a health care bill to "repeal" the Affordable Care Act. Now I confess that I've only skimmed portions of it, and I suspect that there will be some "deal making" going on to amend the proposal in an attempt to gather the necessary votes for it to pass. I don't intend this to be a political post, although the title probably makes you think I do. But depending on what happens, couldn't a crisis be looming as a result, at least for those individuals in nursing facilities whose stays are covered by Medicaid? Whether per capita caps or block grants, the potential remains that there may be less money to cover long term stays in nursing homes, right?
What got me thinking about this post was an article in the New York Times on June 24, 2017. Medicaid Cuts May Force Retirees Out of Nursing Homes asks the question, what happens if Medicaid cuts are enough to affect coverage for long term nursing home care? "Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage." One expert interviewed for the story suggested that even if the ACA isn't repealed, Medicaid is still an attractive target for cuts and don't forget that long term nursing home care makes up a significant amount of Medicaid spending, "long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them." The article considers the possibilities of cuts and the impact both on the facilities and the residents.
Justice in Aging released a blog post, issue brief and fact sheet focusing on the impact the Senate version of the bill will have on elders. The Fact Sheet, discussing Caps lists 5 downsides to the states and 3 ways elders will be harmed. Since the Times article was focused on nursing facility coverage, here's what the Justice in Aging Fact Sheet says about that: "Losing Coverage for Nursing Home Care. 62% of nursing home residents rely on Medicaid. For the vast majority of these 850, 000 nursing home residents, Medicaid coverage is provided through an eligibility category that is "optional" under federal Medicaid law. As states face insufficient funding, they will look for optional categories to cut, putting nursing home residents at particular risk." Both the Issue Brief and the Fact Sheet fail to take into account the aging of America by tethering the cap to "baseline years". As the Brief notes
[T]he fourth problem is that the Senate bill’s per capita cap fails to recognize how increasing age corresponds to a greater need for health care. In 2011, for example, persons aged 85 and over incurred average Medicaid costs that were 2.5 times higher than the average costs incurred by beneficiaries aged 65 to 74.35
Assume that a state currently has a large percentage of Medicaid beneficiaries in their early 70s. The base rate for that state will be weighted heavily towards the average health care needs of persons in their 70s, and that weighing will affect the cap amounts imposed in 2027, when the large group of beneficiaries will be in their early 80s — with different and more extensive needs for health care. Notably, such a shift in population from the young-old to the old-old is more likely than not, given the overall aging of America’s population. From 2025 and 2035, approximately two-thirds of the states will experience a rise in the share of seniors who are 85 and older. In most cases, the increase will be at least 25%. (citations omitted).
If these folks in nursing homes need a level of care that can't be provided by their families (if they even have families) and Medicaid is cut, what's the answer? Right now, all we can do is wait and see what happens with the Senate this week. Right now, the vote is projected to take place on Thursday.
Wednesday, June 21, 2017
According to a recent article in the Washington Post, not all family caregivers of vets are treated equally. Law makes VA treat some family caregivers better than others explains that for "veterans injured on duty, Uncle Sam pays more attention to some of their caregivers than others. The law allows the government to provide caregiver services for vets injured on Sept. 11, 2001, or after, but not those injured before that ...." On June 19, 2017, the Disabled American Veterans (DAV) organization released a report about its efforts, the "Unsung Heroes Initiative" to change the law. The DAV describes this, according to the article, as “a national campaign to raise awareness about the service and sacrifice of caregivers to America’s severely disabled veterans as well as the inequities of supports available, particularly for those injured before 9/11.” Bills are before Congress to change the law "that would make all veterans, no matter when they served, eligible for the caregiver support." The article also references a recent Veterans' Affairs Committee hearing on budgets, with testimony, etc. available here.