Access to health care services promotes student success

This is the second of a Back to School blog series (see Part 1, Part 3, Part 4 and Part 5) that highlight various issues to be aware of as the 2016-17 school year kicks off.

Investing in school-based and school-linked health services would help ensure that students receive the physical and behavioral health care they need to reduce chronic absenteeism and improve school performance. Ensuring that all students attending public school have access to basic health care services would help address and improve realities that do not bid well for the health and education of many of our students.

Approximately 6 to 7 percent of school-aged children miss 11 or more days of a typical school year in North Carolina because they are sick or injured. Around 6 percent of school-aged children do not have health coverage, and many low-income families and children face additional social, environmental, and financial barriers regarding access to health care services (e.g. a parent’s ability to take time off work to take their child to the doctor). Nationally, around 27 percent of children 19 years and younger have a chronic health condition, which may affect school achievement and attendance.

These are realities that we can and should address.

School-based health centers (SBHC) and school nurses are in a special position to help increase access to health services for children as their role is to collaborate with school personnel and other community groups that work with schools. Thus, SBHC staff and school nurses are capable of not only educating students about school violence, healthy behavior promotion, and disease prevention, but they also can work with teachers, parents, and school personnel on promoting school policies that promote a safe and healthy school environment. School nurses and SBHC staff can provide health care services if a child is injured, participate in crisis intervention, and make referrals to other health services. North Carolina has a persistent deficit in regards to school nurses. Health People 2020 recommends that the proportion of full-time registered nurse to student ratio be 1 nurse for every 750 students; however, North Carolina has a ratio of 1 nurse for every 1,177 students, which is far from the recommended ratio.  Moreover, only 90 SBHCs serve just 25 of North Carolina’s 100 counties.

North Carolina lawmakers have several opportunities to strengthen children’s ability to gain health coverage and receive affordable health services. Expanding Medicaid is one opportunity as more than half of parents in the current health insurance coverage gap have school-aged children.  When parents have health coverage, children are more likely to be enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).  Furthermore, changes at the federal level now enable schools to bill the Medicaid program for health services provided to Medicaid-eligible children. In 2012, nearly 1 million North Carolina children ages 18 and younger had Medicaid health coverage. Currently, schools are only reimbursed for health services provided at school if the services are medically necessary and if the student is eligible for both Medicaid and special education. Accordingly, North Carolina’s education and health agencies can work together to develop a state plan amendment so that all Medicaid-eligible children can receive the behavioral and physical health care they need.

Through thoughtful public policy decisions and collaboration, we can ensure that North Carolina students have all the tools they need for a successful school year, including access to health care services.

 

The key to transformative Medicaid reform is Medicaid expansion

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Last week, providers, policymakers, NC DHHS administrators, and Governor McCrory enjoyed publicity as the governor signed off on the 1115 waiver application to reform North Carolina’s Medicaid system during a press event. In his letter to US DHHS Secretary Burwell, Gov. McCrory writes that the 1115 waiver “will allow North Carolina to implement innovative reforms to Medicaid and NC Health Choice (CHIP) programs.”  The content of the waiver explains that the goal of the waiver demonstration is to achieve the “Quadruple Aim”: 1) Per capita cost containment and funding stability, 2) Better health in our community, 3) Better experience of care, and 4) Improved provider engagement and support. The quadruple aim aligns with goals set by many states and the federal government as health providers, advocates, and lawmakers understand the importance of improving quality while decreasing or maintaining costs.

Unfortunately, NC policymakers continue to ignore one key element of the ACA that will strengthen the Tar Heel state’s ability to reach the quadruple aim – Medicaid Expansion. Just one week after the Medicaid reform press event, Georgetown‘s Center for Children and Families released a report on how closing the coverage gap not only increases individual access to health care, but has a huge impact on safety net hospitals and clinics. The report highlights themes from federally qualified health centers (FQHCs) in seven states, three of which did not close the coverage gap. Among expansion states, key themes in the findings align perfectly with North Carolina’s quadruple aim for Medicaid reform.

First is the economic benefit. By reducing the amount of uncompensated care, safety net providers are less likely like to experience fiscal distress. This is especially important considering that North Carolina has 16 vulnerable hospitals. Second, as a result of more savings, many health providers in expansion states were able to either open new facilities or expand services that ultimately improve community health. Third, the report states that while there is still difficulty addressing specialty care, they have greater capacity to improve access to specialty care, which could then improve patients’ health care experience. Fourth, providers in states that have extended coverage to those in the coverage gap are more likely to report improved provider engagement and communication which helps coordinate care and bolster efforts to integrate physical and mental health care. After reading the report and other evidence examining the benefits of Medicaid expansion, it seems that NC policymakers have ignored a key component in implementing a truly transformative and innovative reform.

Zika: A new reason to expand Medicaid

While Congress continues to debate whether to allocate $1.9 billion to combat the Zika virus, state policymakers are urging Congress to take action in addition to calling on their state public health departments to begin efforts to prevent and monitor the spread of Zika. However, state-level efforts may be minimal given that the Great Recession led many states to cut spending on public health initiatives. North Carolina has continued to cut public health spending since 2013, which not only impacts the state’s public health infrastructure, but the health department’s capacity to address potential outbreaks like Zika or even Ebola while continuing surveillance of other public health concerns like the flu. This fiscal year, both the House and Governor McCrory allocate $750,000  in their respective budgets to strengthen NC’s public health infrastructure to conduct surveillance of the mosquito that acts as a vector for the Zika virus, detect the spread of Zika, prevent, and respond to the potential outbreak. The Senate’s budget only has a net appropriation of $477,500 to address the potential Zika epidemic in NC.

Despite federal and even NC policymaker’s decision on how much to fund Zika detection and prevention, other federal agencies recognize the urgency to research, prevent, and respond to the spread of the Zika virus in the U.S. The CDC activated its Emergency Operations Center (EOC) in January, advanced its activation to the highest level in February, and has borrowed $50 million from other public health efforts to jump-start its efforts in fighting Zika. Last week, CMS issued a letter to state Medicaid programs outlining services that will aid in the detection, prevention, and treatment of Zika. In the letter, CMS states that Medicaid dollars can help with prevention efforts such as prescribing repellents and providing family planning counseling; support detection efforts through testing for Zika; and respond to Zika by offering long term services and supports to children and individuals with Zika-related disabilities and even offer extended Medicaid services to pregnant women. As recently as June 1st, the CDC reported that there were 618 cases of Zika in the U.S., 12 of which are in NC. While no cases of Zika have been acquired locally, there are approximately 300 pregnant women in the U.S. that may have been infected, and 3 babies have been born with Zika-linked health concerns. It is also important to note that there is no vaccine for Zika and that  health researchers are still learning about the health outcomes in babies (such as microcephaly) and even about the sexual transmission (including oral sex) of Zika.

Given that the official start of summer is just a few weeks away, people have plans to go on summer vacation (potentially to places that increase one’s risk of acquiring the Zika virus), and are spending more time outside with mosquitos, NC should do all it can to address the potential long term fiscal and health impacts of Zika. Considering CMS’ statement last week, the one obvious way to boost NC’s efforts to detect, prevent, and treat Zika is Medicaid expansion. NC’s Medicaid program would receive increased levels of federal dollars to provide health care to Tar Heels in the coverage gap, which would help combat Zika. In NC there are 500,000 individuals that could be at risk as they lack health coverage to seek help in detecting and preventing the spread of Zika. Without Medicaid expansion, health providers may have to provide more uncompensated care or families may face financial instability as they try to pay for long term health services. Instead of passing legislation that has zero impact on “protecting” mothers and children, NC lawmakers should expand Medicaid which has evidence of protecting and promoting the health of children, families, and individuals.

Advocates continue to press for Medicaid expansion

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Advocates, providers, and people in the coverage gap gathered at the General Assembly yesterday to champion for Medicaid expansion. When NC legislators passed SB 4 in 2013, which purposely blocked the state from closing the coverage gap, advocates knew that it would take continued action of many to ensure that NC legislators understand the health, social, and economic benefits of Medicaid expansion.

The press event hosted by Sen. Floyd McKissick at the General Assembly was the culmination of a week of activities that helped raise awareness about the impact of failing to extend coverage to approximately 500,000 people in the coverage gap. On an individual level, Medicaid expansion will increase people’s ability to receive less costly preventive care and improve people’s ability to manage chronic medical conditions instead of relying on emergency care. Sonya Taylor, who is in the coverage gap, shared her story during the press event. Ms. Taylor noted that she has to rely on the support of church, family, and friends not just to deal with the pain, but to be able to afford to see a primary care provider. She works and saves money, but because of the complexity of her medical condition, she cannot report good health because occasional visits to a primary care doctor are not enough.

Ignoring the call to expand Medicaid also impacts entire counties. As Dr. Charlie van der Horst said during his speech, residents in low-resource counties such as Scotland, Vance, Caldwell, Anson, and Lenoir counties are two times more likely to die prematurely than residents of more affluent counties like Wake County. Statewide, closing the coverage gap could prevent 1,000 unnecessary deaths each year. When you consider the fact that many rural hospitals are especially vulnerable to closing without the financial boost they would receive from Medicaid expansion, many more children, families and working adults are likely to face poor health outcomes.

On the state-level, lawmakers rejected 43,000 jobs by 2020 when they failed to expand Medicaid this year. Each year that legislators refuse increasing access to health care to nearly a half million North Carolinians, they are also failing to accept $2 billion in federal funds. Refusing to close the coverage gap also prevents approximately 144,000 children from receiving necessary health care because they lack health coverage. Further, 29,000 fewer individuals in NC would report experiencing depression each year if lawmakers would expand Medicaid. Each year policymakers fail to the close the coverage gap, 40,000 women do not receive preventive screenings. While the day of advocacy is over, we must continue to remind legislators that closing the coverage gap is a not a political game, but a policy that impacts the health and economic well-being of children, workers, families, communities, and the entire state.

The truth about the Governor’s proposed “Medicaid expansion”

Medicaid expansionThere’s been a lot of talk of late emanating from the McCrory administration about “expanding Medicaid.” Unfortunately, a close look at the fine print makes clear that the minor proposed “expansion” has absolutely nothing to do with closing the state’s massive Medicaid coverage gap that has resulted from our failure to expand the program under the terms of the Affordable Care Act.

Both the North Carolina Medicaid and NC Health Choice Draft Section 1115 Waiver application written by the state Department of Health and Human Services (DHHS) and included in the Governor’s 2016-2017 proposed budget presentation use the word, “expansion,” freely. Unfortunately, neither the Governor nor DHHS have committed to closing the coverage gap or truly expanding Medicaid so that nearly one-half million North Carolinians can have access to health services. To be clear, closing the coverage gap means extending health coverage to individuals at or below 138 percent federal poverty level, which is an annual income of $16,394 for an individual and $33,534 for a family of four in 2016.

The 1115 waiver is for Medicaid “reform,” NOT Medicaid expansion. As you may recall, DHHS and the General Assembly want to transform our current nationally recognized primary case management system to managed care, where both commercial insurers and “provider led entities” would administer Medicaid services.

The waiver proposal reports that North Carolina will embark upon a tiny “expansion” of Medicaid whereby parents whose children enter the foster care system can access health care services in order to strengthen family stability. Unfortunately, this “expansion” is only for parents who already meet income eligibility for Medicaid when their children are in the home. Currently, once their children are removed from the home, parents previously enrolled lose their benefits. In other words, while welcome, all the proposed change does is alter a minor, extremely illogical rule.

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