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Commentary

After reading this fact sheet from the American Public Health Association (APHA), it is apparent that NC policymakers need to take action in order to improve our state’s public health. If our state legislators were assigned a grade for how they are investing in NC’s public health, it would not be a passing grade. The following statistics show there is much room for improving NC’s public health rankings:

  • Ranks 8th for prevalence of diabetes amongst adults.
  • Ranks 47th for the availability of dentists.
  • Ranks 10th for infant mortality.
  • Ranks 47th for the amount invested in each person’s public health needs. NC spends $11.73 per year per resident.
  • Ranks 5th for the number of children living in poverty.

While these numbers are unimpressive at best, there are some public health areas that NC has improved on. First, the high school graduation rate has improved, but then again the Senate budget proposes tax cuts that lower the number of teacher assistants, which could negate the progress made. Second, NC has made great progress in reducing air pollution, but then again the House wants to cut auto emissions tests in some counties.

Even though the sequester led to significant cuts in public health funding, there is federal funding available to address the poor rankings listed above. NC could receive funding to help the following:

Fifteen percent of North Carolinians are uninsured and 500,000 people are in the Medicaid coverage gap. These are people that could seek primary preventative health care that will yield better health outcomes such as prenatal and maternity care to ensure healthy outcomes after childbirth. Research has shown that children eligible for Medicaid miss fewer school days, have higher educational attainment. and their families have more financial security. There are also 150,000 people in NC in the coverage gap with mental health and substance use disorders that need ongoing treatment. The Affordable Care Act has written into law that the federal government will cover 100% of Medicaid expansion costs until 2016 and up to 90 percent of costs starting 2020. Ensuring coverage to one half million North Carolinians is one public health act that will pull NC up the rankings.

Commentary

As Adam Linker noted yesterday in the post below, there are no more excuses now for Gov. McCrory:

“Now that the Supreme Court has ruled — again — that the structure of the Affordable Care Act is constitutional, it is time to move forward with making the law work better in our state.

The first, and most important, step is accepting federal funds to extend the benefits of affordable health insurance coverage to 500,000 more people in our state. Gov. McCrory said last year that his staff was assembling options to expand coverage and that he would make an announcement about his recommendation after the Supreme Court ruled in King v. Burwell. The ruling has arrived.”

This morning, major newspapers around the state are echoing this sentiment.

From the Durham Herald-Sun:

“With the question of the act’s validity answered by the court, it’s time for North Carolina
to reverse its unfortunate decision to not extend Medicaid coverage to an estimated
500,000 individuals and families too poor to qualify for the ACA subsidies.”

From the Greensboro News & Record:

“This was an enormous victory for President Obama. Most importantly, it avoids the human toll that would have resulted from an adverse ruling.

Next, North Carolina should expand Medicaid coverage for thousands of residents who still fall between the coverage cracks. State leaders should have expanded Medicaid in the first place, but seemed more intent on thumbing their noses at the president than doing what’s right. Not only is most of its cost paid for by the federal government, but also it would create as many as many as 43,000 jobs. Gov. Pat McCrory had said he wanted to wait for the Affordable Care decision first before considering that step. Now that the high court has ruled, it’s time for him to act.”

From Raleigh’s News & Observer:

“Meanwhile, Gov. Pat McCrory has shown a lack of political courage in declining to support an expansion of Medicaid, the state and federal insurance program for the poor and disabled. The federal government, under the Affordable Care Act, would pay 100 percent of the expense in the first three years and at least 90 percent thereafter. McCrory said he was awaiting the high court decision to make his own decision about pushing for Medicaid expansion. But he wasn’t. Once again, the 500,000 North Carolinians who could be helped are left to hope that a move to expand Medicaid comes before an illness or an accident does.”

In other words, come on Governor, get off your keister do the right thing!
Commentary

While many of us are anxiously waiting for the Supreme Court decision on King v. Burwell, a recent poll shows that 44-percent of people still don’t know much about the case.

The King v. Burwell ruling will determine the legality of health insurance subsidies for states using the federal marketplace. If the Supreme Court rules against the Affordable Care Act (ACA) and decides that health insurance subsidies for the 34 states that do not have a state marketplace are “illegal,” more than six million people across the U.S. may lose their ability to access affordable health care. Since they live in one of the states that rely on the federal marketplace, 458,738 North Carolinians could lose their health coverage. Nationally, the average subsidy (or advance tax credit) amount is $272 per month and in North Carolina, people receive $316 per month.

Considering that subsidies could become unavailable as early as September 2015 and that North Carolina has failed to expand Medicaid, the number of uninsured could increase to nearly one-million people. Sylvia Burwell, the Secretary of Health and Human Services, has stated that if there is a negative outcome from the Supreme Court decision on King v. Burwell, the U.S. Congress and state policymakers will have to decide on how to keep access to health coverage affordable.

As data continue to show that the ACA is working to increase access to care – for example, the rate of uninsured women has decreased nearly eight percent since 2013 and 12.2 million adults have access to health care in the 30 states (including DC) that have expanded Medicaid – state lawmakers and Congress may be feeling even more pressure to keep subsidies. Even the Congressional Budget Office has reported that gutting the ACA would increase the deficit by $137 billion by 2025. Despite the potential economic impact, media reports continue to highlight the fact that conservative policymakers in Washington D.C. do not have a better alternative to the ACA. Further, one “fix” proposed by Sen. Ron Johnson of Wisconsin would only extend subsidies for current ACA enrollees until 2017.

If the outcome of King v. Burwell isn’t positive, let’s hope that our state and national policymakers work to keep 6.4 million people insured. No matter how the Supreme Court rules, let’s hope that our state policymakers will take on the next challenge – extending access to affordable health care to 500,000 North Carolinians in the coverage gap as Medicaid expansion makes economic and moral sense.

Commentary

Since 1978 North Carolina’s Medicaid program has been managed by the Division of Medical Assistance, which is within the NC Department of Health and Human Services (DHHS). As the state’s Medicaid program stands today, most Medicaid enrollees are categorically needy – in other words, aged, blind, disabled or very low-income families (including pregnant women). As Medicaid enrollment has grown from under 500,000 enrollees in 1978 to over 1.5 million enrollees in 2015 so have the expenditures. Even though Medicaid spending growth between 2007 and 2012 was less than growth in private health insurance premiums, many states are reforming Medicaid to enhance budget predictability, increase quality of care, and promote long-term cost savings as enrollment increases. NC is no different as both the House and Senate have recently released their plans for Medicaid reform.

The House Medicaid reform bill was discussed in a previous post, but here is a quick recap. The House reform bill aims to build upon the system NC already uses by establishing provider led entities (PLEs). As the transition takes place, the PLEs can rely on the expertise and knowledge of Community Care of North Carolina. This model is similar to an Accountable Care Organization (ACO) approach in that networks of providers such as hospitals and doctors take responsibility for not only coordinating patient care, but for the finances. This model moves away from the current fee-for-service payment model, which rewards quantity of medical visits and/or procedures over quality of care and ultimately increases costs to providers taking a capitation payment. Capitation payment allows for providers to take on financial responsibility as they receive one risk-adjusted payment per patient. Providers in an ACO work to refer patients to other providers within the network. It is important to note that patients can select a provider outside of an ACO at no additional cost. Finally, five million dollars has been provided to reform Medicaid over a five year period in the House bill.

The Senate budget provides 10 million dollars to reform Medicaid by 2017. Like the House Medicaid reform bill, the Senate also includes the transition from a fee-for-service model to a capitation payment model. One major difference is that instead of using one type of organization to provide care and take financial responsibility, the Senate’s version of Medicaid reform uses a hybrid model. NC would contract with outside Managed Care Organizations (MCOs) who would then work with regional PLEs to provide care to Medicaid enrollees. Another significant difference between the two reform bills is that the Senate’s version of reform would remove oversight of Medicaid from DHHS to a new Health Benefits Authority, an eight member board focused on Medicaid and NC Health Choice. What is interesting is that members of the board would be appointed by the Governor, President Pro Tempore of the Senate, Speaker of the House of Representatives, and Secretary of Health and Human Services .

No matter how NC lawmakers ultimately decide to reform Medicaid, there is one action that both versions fail to do – expand Medicaid to 500,000 North Carolinians in the coverage gap. The same waiver that policymakers will submit to CMS to reform Medicaid can also be used to expand Medicaid as many other states have done.

Commentary

Yesterday, the highly anticipated Medicaid Modernization Act or Medicaid reform bill  was described as transformative, innovative and the dawning of a new day by members of the House Health Committee. During the morning meeting, Representatives Dollar and Lambeth explained that the aims of Medicaid reform are to produce long-term cost savings, budget predictability, as well as increased patient satisfaction and quality of care through building upon North Carolina’s current medical home model. House bill 372 will implement an accountable care organization (ACO) model by establishing provider led entities (PLEs) with a full-risk capitation payment method (providers will receive a risk adjusted payment per patient). This is a move away from the “traditional” fee-for-service payment model. Further, transitioning to ACOs and a capitation payment method is supported by CMS for Medicare  as it promotes coordinated care and de-incentivizes providers from ordering numerous medicals tests and procedures that increase Medicaid costs. What is more, early results from Oregon, Colorado and Minnesota are showing cost savings for Medicaid ACOs. The Medicaid reform bill is positive in that it will build upon North Carolina’s current system and rely on the expertise and knowledge of Community Care of North Carolina. However, this bill has received some early criticism for being too similar to previous Medicaid reform bills, including carve outs for local management entities/ managed care organizations which handle dual eligible patients, and lacking clarity concerning how patients that do not select a PLE will be auto-assigned.

Despite the above mentioned factors that may draw skepticism from the Senate, we cannot say that the reform bill is a major movement forward as it does not include Medicaid expansion. The reform bill outlines that the new PLE model with full-risk capitation will cut spending growth by a minimum of two percentage points as compared to non-Medicaid expansion states. When referencing the success of states with ACO Medicaid models during the committee meeting – Colorado, Minnesota, New Jersey, Oregon, Massachusetts, and Vermont – representatives failed to say that these are states that also expanded Medicaid. In other words, North Carolina can expand and reform at the same time too. As the committee brought up issues of the economic feasibility of Medicaid reform, our policy makers are ignoring that Medicaid expansion will bring nearly $2 billion in federal funding per year to our state. More importantly, by expanding coverage, our legislators will move the conversation from business to people. There are 500,000 North Carolinians that lack access to affordable health care and 1,000 unnecessary deaths annually by refusing to extend health coverage to people in the coverage gap. Expanding Medicaid is transformative and innovative as it allows for reform while improving health care access and quality for all.