Posts Tagged ‘Medicaid’
February 8th, 2014
State ReforUM tracks state-level health care reforms. Check out their updated map of what states are doing in expanding Medicaid, pursuant to the Affordable Care Act (ACA). See the story on what South Carolina is up to.
February 7th, 2014
South Carolina’s The State newspaper reports that the state Medicaid program will start paying physicians and dieticians to treat obesity among the state’s Medicaid population. The State’s article states, “The anti-obesity coverage would pay for up to six visits a year with a physician and six visits with a licensed dietitian, a nutrition specialist who has a five-year degree who also is registered with the state. State officials estimate about 86,000 people, or 60 percent of South Carolina’s obese Medicaid recipients, would participate.
If 60 percent do participate, officials estimate that the cost to the state’s Medicaid program would be an extra $10.5 million. Most of that money would come from the federal government. However, $3 million would come from state taxpayers.
The state’s Medicaid agency has requested the taxpayer money. But even if lawmakers reject that request – unlikely given the support of Haley and legislative Republicans and Democrats – the agency says it still will start the program by cutting other programs in its budget.
October 4th, 2013
The Affordable Care Act’s major impact on persons with obesity is historic. Assuming that 34% of the 170 million adults with employer-based health insurance are obese, 57.8 million adults with obesity will be protected from losing coverage due to pre-existing conditions, have no annual or lifetime caps, a right to external, independent review of denied claims, rights in employer wellness programs and a new benefit, intensive behavioral counseling for obesity. An estimated five million persons with a BMI >30 may enroll in Medicaid and be eligible for intensive behavioral counseling for obesity, if all those eligible enrolled. The same is true for an estimated 3.8 million American adults under the age of 65 with obesity eligible to enroll in the state exchanges. In state exchanges, a strong non-discrimination provision based on “benefit-design” appears to provide the legal foundation to expand coverage of drugs for the treatment of obesity and bariatric surgery. In short, an estimated 66.6 million Americans with obesity will have new protections, rights and benefits on January 1, 2014.
See details on changes in current private insurance plans, Medicaid, state exchanges, prevention, research and restructuring of the health care system.
Christopher Still and I have written up the full details in this new 15 page report: The Affordable Care Act.
December 26th, 2012
Below are my comments about the lack of inclusion of obesity treatments in the definition of essential health benefits under the Affordable Care Act.
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Baltimore, Maryland Re: Standards Related to Essential Health Benefits (EHB)
Thank you for the opportunity to comment on CMS-9980-P, establishing standards related to essential health benefits.
The proposed regulation is a missed opportunity to effectively address one the nation’s major health crises- obesity. There is no need to repeat the well-covered statistics on the nation’s obesity prevalence nor on the extensive impact on personal health caused or made worse by obesity. Suffice it to say that obesity is recognized as a major driver of poor health care, of high utilization of healthcare services and of high, and growing, national health care expenditures.
The proposed regulation establishing standards for essential health benefits (EHB) will have an enormous reach. Non-grandfathered plans in the individual and small group markets, both inside and outside the exchanges, multi-state plans, Medicaid benchmark and bench-mark equivalent, and Basic Health Programs must cover EHB by January 1, 2014. However, the proposed regulation is deficient in its failures to address this national health epidemic.
The proposed regulation fails the test of comprehensiveness
The Affordable Care Act establishes ten categories of ‘essential health benefits’. One of these is “Preventive and wellness services and chronic disease management.” However, the proposed regulation do not define this category in general nor address obesity specifically. Traditionally, these areas have been either ignored or underserved by health insurance programs. Yet, the structure of the EHB regulation relies entirely on already established health insurance programs for its ‘benchmark’ plan.
According to the Obesity Action Coalition, only 22 states have chosen benchmark plans that cover bariatric surgery. Only 5 states have chosen benchmark plans that cover weight loss programs. 28 states have chosen benchmark plans that cover neither bariatric surgery nor weight loss programs. (Source: Obesity Action Coalition http://www.obesityaction.org/wp-content/uploads/1212-OCC-Summary-of-Obesity-Treatment-State-Benchmark-Plan-Coverage.pdf, accessed December 26, 2012)
Few governmental or private health plans provide coverage of Food and Drug Administration approved drugs for the treatment of obesity. Many health insurance plans have explicit exclusions for weight loss. Medicaid coverage is also poor. Eight state Medicaid programs appear to cover all recommended obesity treatment modalities for adults. Only 10 states reimburse for obesity-related treatment in children. In the small group market, 35 states expressly allow obesity to be used for rate adjustments while 10 states allow it in the individual market. Only 5 states provide coverage of one or more treatments in both the small-group and individual markets. (Lee JS, Sheer JL, Lopez N, Rosenbaum S, Coverage of obesity treatment: a state-by-state analysis of Medicaid and state insurance laws, Public Health Rep. 2010 July-August;125 (4): 596-604)
The Medicare program itself is a more positive model. In 2004, Medicare eliminated language in its coverage manual that obesity was not a disease. In February 2006, CMS significantly expanded its national coverage policies to cover more bariatric surgery procedures when performed in designated centers of excellence. In 2011, CMS added intensive behavioral counseling for adult obesity (A grade B recommendation of the U.S. Preventive Services Task Force). As yet, Medicare Part D does not cover drugs for the treatment of obesity.
It is a questionable health policy which covers counseling and surgery for American adults over age 65 when, by this regulation, the same coverage could be extended to younger Americans with obesity for whom the interventions are likely to be more effective in improving health outcomes and reducing the need for expensive treatments of related comorbid conditions. Perpetuating this scattered picture of health insurance coverage makes no sense, especially in the context of implementing the Affordable Care Act.
Further, a companion proposed regulation on employer wellness program would allow overweight or obese employees to be penalized up to 1/3 of the cost of their health insurance plan if they failed to meet employer-determined biometrics, such as weight or Body Mass Index. Yet, under this proposal, their employer’s health plan (or exchange or multi-state plan) would not be providing the employees with the treatments they need to obtain that goal. This is unlike the situation for high blood pressure, high cholesterol or type 2 diabetes where treatments are almost always covered in insurance plans.
Recommendation: The regulation should define EHB to include behavioral, pharmacological and surgical interventions based on the evidence‐based recommendations of the National Institute of Health/National Heart, Lung and Blood Institute. The guidelines for treatment of adult obesity were issued 1998, and are currently being updated, see http://www.nhlbi.nih.gov/guidelines/obesity/obesity2/index.htm Regarding children and adolescents, the American Academy of Pediatrics and 15 national medical societies have adopted guidelines which can be incorporated into the regulation.
The proposed regulation fails the test of non-discrimination
Section 156.125 provides, “An issuer does not provide EHB if its benefit design, or the implementation of its benefit design, discriminates based on an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions.”
While this is elegant language, it is doubtful that, given insurance practices, it is enough to overcome the inherent prejudice, stigma and discrimination directed at persons with obesity. The insurance industry’s current exclusion of obesity treatments is exactly because of expected length of life, present or predicted disability, degree of medical dependency, quality of life and other health conditions.
Keep in mind that overweight and obese employees already receive a wage penalty because of their weight. A recent study has confirmed that obese employees with employer-provided health insurance are paid less than their peers because of higher health care costs. Stanford University researchers analyzed data from the Bureau of Labor Statistics, the National Longitudinal Survey of Youth and the Medical Expenditure Panel survey. They found that, on average, obese employees with health insurance were paid $1.42 an hour less that non-obese workers. Women had a higher wage penalty than men. Women with obesity whose employers provided health insurance paid a wage penalty of $2.64. (Bhattacharya, J, Bundorf, MK, The incidence of the healthcare costs of obesity, Journal of Health Economics 2009: 28:649-658.)
Recommendation: Section 156.125 should make clear that a plan design which excludes bariatric surgery, FDA approved drugs to treat obesity, intensive behavioral counseling is, ipso facto, discriminating against persons with obesity. Additionally, it is not enough to just have the states monitor and identify discriminatory designs. A federal office needs to be designated where complaints or inquiries can be addressed.
Health reform must address one of the root causes of mortality and morbidity in the country. Without fully including evidence‐based interventions for obesity, it is hard to foresee a net improvement in the health of Americans. The current situation of health insurance, in its avoidance of obesity prevention and treatment, perpetuates a focus on the conditions caused by obesity. Millions of dollars spent on heart disease or type 2 diabetes (not to mention the other ill effects) will only continue.
October 17th, 2012
If you follow developments in obesity at all, you are familiar with the CDC maps showing the increases in obesity across the nation. Likewise, it is clear from these maps, the obesity is a major problem in the South.
Unfortunately, and tragically for many obese poor persons, the governors of Florida, Louisiana, Georgia, South Carolina and Texas have now been joined by the governor of Mississippi in rejecting the expansion of Medicaid in their states. The expansion is authorized under the Affordable Care Act (Obamacare). St.LouisPostDispatch_Mississippi Decides Medicaid Dollars not Worth Cost
Under the Affordable Care Act, the federal government will pay 100% of the cost of expanding Medicaid from 2014 to 2016. Between 2017 and 2020, the federal share drops to 90% and the states’ contribution gradually rises. The Kaiser Family Foundation projected that Mississippi would receive $23 dollars from Washington for every $1 from the state.
While state budgets are clearly under pressure, many see politics at work as all of the Governors in these states are Republicans and are opposed to Obamacare. Regardless, Mississippi has the highest rate of childhood obesity in the nation with nearly 40% of children up to age 17 meeting the obesity criteria. In all of these states, the lower income groups, who would be covered by the expansion of Medicaid, have major health problems. Refusing to participate in the Medicaid expansion only perpetuates these issues.
August 30th, 2012
Among the provisions in the Republican Party Platform adopted this week in Tampa, Florida are these affecting obesity:
Food stamps and other nutrition programs be sent in block grants to the states.
On Medicare and Medicaid, the platform states, “The problem (with these programs) goes beyond finances. Poor quality healthcare is the most expensive type of care because it prolongs afflictions and leads to ever more complications. Even expensive prevention is preferable to more costly treatment later on. When approximately 80 percent of healthcare costs are related to lifestyle – smoking, obesity, substance abuse – far greater emphasis has to be put upon personal responsibility for health maintenance. Our goal for both Medicare and Medicaid must be to assure that every participant receives the amount of care they need at the time they need it, whether for the expectant mother and her baby or for someone in the last moments of life.”
Editor’s note: This paragraph is rather hard to discern. On the one hand, it seems to be an blank check for prevention programs which are, overwhelmingly, governmental programs. Yet, then it shifts to personal responsibility. Then, a neck-whipsawing shift to Medicare and Medicaid participants getting every service they need when they need it. So, what exactly does this mean? Do you get bariatric surgery, for example, when you need it? Or is it denied because you did not take “personal responsibility?”
Regarding Medicare, the platform calls for making the program into a “premium support” program for those age 55 and younger. For these individuals, Medicare would provide a voucher to go out and purchase private health insurance coverage. Currently, Medicare covers bariatric surgery and intensive behavioral counseling for both those over age 65 and those disabled and receiving Social Security disability. Frankly, I am skeptical that private insurance companies (which did not insure elderly persons before Medicare was enacted) would cover such persons and such services without prohibitively high premiums.
For Medicaid, the platform proposes “alternatives to hospitalization for chronic health problems. Patients should be rewarded for participating in disease prevention activities. Excessive mandates on coverage should be eliminated. Patients with long-term care needs might fare better in a separately designed program.”
Editor’s note: The platform does not describe what an “alternative to hospitalization” would be. The reference to “patients with long-term care needs” refers to millions of elderly Americans whose nursing home costs are paid for by Medicaid, after their own assets are exhausted. It has been a politically charged issue to make the spouse’s assets at risk for the patient’s nursing home costs. This was proposed in the Ryan Budget. What a “separately-designed” program would be was not specified.
Of course, the platform calls for the repeal Obamacare or the Affordable Care Act “in its entirety.” This would include free intensive behavioral counseling for adults with obesity under plans which were not grandfathered, grants for healthier communities, access to breastfeeding sites at work, access to health insurance by persons whose obesity has prevented them from getting insurance due to a “pre-existing condition, and greater rights for individuals to fight denials of claims.
Of course, also repealed would be the regressive provisions for “workplace wellness” programs which penalize overweight workers for not meeting weight targets set by their employers.
In 2008, The Republican Party Platform, adopted in St. Paul, Minnesota, provided:
“Prevent Disease and End the “Sick Care” System. Chronic diseases – in many cases, preventable conditions – are driving health care costs, consuming three of every four health care dollars. We can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including improved nutrition and breakthrough medications that keep people healthy and out of the hospital. To reduce the incidence of diabetes, cancer, heart disease and stroke we call for a national grassroots campaign against obesity, especially among children”.
June 24th, 2012
The New York Times reports on the issue of Texas, which has one of the highest rates of obesity in the country, grappling with the costs of bariatric surgery in Medicare and Medicaid. NYT:Spending for Weigh Loss Surgery Increases in Texas
No doubt this scenario will be played out in many states in the coming years. I’ve always said, “Obesity is too expensive to treat and it is too expensive not to treat.” This article bears this out. The tipping point for me is that at least with treating, we are reducing suffering for some humans. Predictably, at the end of the article a professor is cited as saying that the state could reach many more people with less expensive lifestyle interventions and improve their health enough to save far more dollars than bariatric surgeries do. This would be true if any lifestyle intervention was shown to achieve bariatric surgery’s long term, significant weight loss, with a reduction in co-morbidities, such as type 2 diabetes. But the professor’s statement is still, after millions of dollars of research on lifestyle changes, only a hypothesis, yet to be established.