Steve Beshear appoints members to health exchange board

Written by
The Courier Journal

FRANKFORT, KY. — Gov. Steve Beshear on Tuesday announced appointments to a 19-member advisory board that will provide recommendations for the new statewide health insurance exchange required under federal health reforms.

The exchange, scheduled to begin operation in 2014, will create an online marketplace for individuals and small businesses to shop for health insurance and compare coverage and costs among competing plans. It will also help individuals and employers enroll in plans and qualify for tax credits.

“We need the insight and experience of a variety of Kentuckians to ensure that the exchange not only meets the requirements of the law, but also meets the needs of Kentuckians who will be looking for affordable health insurance,” Beshear said in a statement.

States are required to establish health insurance exchanges under the Affordable Care Act and must demonstrate readiness to run them by the end of the year. Otherwise, the responsibility falls to the federal government.

According to Beshear’s office, the appointees have experience in health benefits, finance and policy, along with public health and the uninsured. The board will review program and policy issues, his office said.

http://www.courier-journal.com/article/20120918/NEWS01/309180100/Steve-Beshear-appoints-members-health-exchange-board

States Seek a Middle Ground on Medicaid

Some Governors Aim to Curtail Program’s Expansion, Steer More People Toward Federally Subsidized Private Insurance

 

By LOUISE RADNOFSKY and CHRISTOPHER WEAVER

A handful of states are considering only partially expanding their Medicaid programs under the federal health-care overhaul—a new twist on how states are interpreting the Supreme Court’s ruling on the law.

Indiana, New Mexico and Wisconsin are among the states asking the federal government to let them omit from the Medicaid expansion residents whose incomes put them just above the poverty level. The states hope to take advantage of provisions in the Affordable Care Act that offer a federal subsidy to help these residents buy private insurance, starting in 2014.

The strategy is the latest fallout fromthe Supreme Court’s June decision, which let states opt out of expanding Medicaid without losing federal funding for the program. A half-dozen governors have already said they would opt out, worried their states will be saddled with extra costs.

State Medicaid-eligibility levels currently vary. Under the law, all states were to open their Medicaid programs to Americans who earned up to 133% of the federal poverty level, which is currently set at $11,170 for a single person. The law also made those with incomes 100% to 133% of the poverty level eligible to buy federally subsidized, private insurance through exchanges.

Some states, however, are asking the Centers for Medicare and Medicaid Services if they can include people in Medicaid up to 100% of the poverty level, but keep people with incomes between 100% and 133% of the poverty level out of the program and instead funnel those people toward the exchanges.

Their main reason: States wouldn’t haveto contribute to the costs of the subsidies to purchase private insurance.

“It’s more expensive for the federal government, but it’s cheaper for the state,” said Seema Verma, a top adviser to Indiana Republican Gov. Mitch Daniels. “Obviously the costs are going to play into it, not just for Indiana, but for every state.”

Allowing partial Medicaid expansions could have broad implications for how the law covers uninsured Americans and add to the cost of the overhaul. The nonpartisan Congressional Budget Office has estimated the federal government would pay about $9,000 of subsidies for each person enrolled in the exchanges, compared with $6,000 for those enrolled in Medicaid.

Federal officials are under pressure tokeep states from opting out of the Medicaid expansion. Hospitals are warning it would leave them with a high number of nonpaying customers, at the same time they are having to absorb federal payment cuts, as a result of the law. Around half of the 30 million Americans expected to gain coverage from the health-care law as it was passed were to gain it through Medicaid.

A report for Indiana’s Family and Social Services Administration by actuaries Milliman, to be released Tuesday, found the state would pay nearly $1.1 billion between 2014 and 2020 to enroll alladults with incomes up to the federal poverty level in Medicaid, but that the full expansion would cost another $326.5 million.

The Department of Health and Human Services has yet to say whether it would let states deviate from the Medicaid expansion as it stated in the law. In other standoffs with the states over the health-care law, the department has tried a conciliatory approach, including offering them the option of jointly running new insurance exchanges.

Erin Shields Britt, a spokeswoman for the department, said it was “evaluating” the question. She pointed out the law covers states’ full Medicaid expansion costs for the first three years and at least 90% in subsequent years. That offers “significant new resources” to states that the administration was “hopeful” they would accept, she said.

Edmund Haislmaier, a fellow at HeritageFoundation, a conservative think tank, criticized Republican-led states forseeking to shift health costs onto taxpayers. “You have the tragedy-of-the-commons phenomenon, where everyone does something in their own interest, but in the aggregate, it’s harmful,” he said, adding that he is advising states not to expand Medicaid at all.

Wisconsin officials have run calculations to figure out the costs of a partial expansion, among other scenarios, saidDennis Smith, health secretary to Republican Gov. Scott Walker. He said thescenario could be attractive to health providers, who want to see the number of uninsured patients reduced but would prefer to be reimbursed by private insurers rather than the government, since private insurers typically pay more.

Officials in New Mexico, led by Republican Gov. Susana Martinez, are also considering a partial expansion, along with other options, said a spokesman for the state’s human services department, Matt Kennicott.

Write to Louise Radnofsky at louise.radnofsky@wsj.com and Christopher Weaver at christopher.weaver@wsj.com

A version of this article appeared September 18, 2012, on page A6 in the U.S. edition of The Wall Street Journal, with the headline: States Seek a Middle Ground on Medicaid.

 

http://online.wsj.com/article/SB10000872396390443720204578002583908495660.html

Most employers signal they will keep offering health insurance

Beginning in 2014, companies can move workers to health insurance exchanges, but a recent survey shows that few plan to do so.

By BOB COOK, amednews staff. Posted Sept. 10, 2012.

In the first few years after the Affordable Care Act is in full effect, physicians are unlikely to see many of their patients’ insurance status change as a result of employers dropping coverage in favor of employees buying individually through health insurance exchanges. Instead, those employed, insured patients will continue to be more responsible for the cost of their care.

Those conclusions came from a report issued by Towers Watson, a global human resources consulting firm. On behalf of the National Business Group on Health, Towers Watson surveyed 440 companies representing 6.6 million employees. The survey was conducted in July and released Aug. 27.

A month after the U.S. Supreme Court had affirmed the constitutionality of the Affordable Care Act, 88% of employers told Towers Watson they had no plans to terminate their health care plans for those working 30 hours or more a week — up from 71% in 2011. Also, 77% of companies said health care benefits were central to rewarding and retaining employees, and 72% said they were not confident — with only 4% saying they were very confident — that health insurance exchanges would provide a viable alternative to employer-sponsored benefits.

Under the ACA, companies that move their insured employees to exchanges, which are designed to provide people with a choice of individual coverage, in 2014 would pay up to a $2,000-per-employee penalty after the first 30 employees if at least one worker receives federal subsidies for the coverage. The exchanges are scheduled to begin in 2014, and the penalty would rise in future years. The Congressional Budget Office has predicted that about 7% of workers in 2014, the year exchanges go into effect, would lose employer-sponsored coverage and buy it from exchanges.

In theory, employers could stop offering coverage now with no penalty at all. Towers Watson, though, said companies don’t consider dropping coverage as a good human relations move. “Affordable health care remains a top priority for employers and a key component in the employee value proposition,” said Randall Abbott, senior health care consulting leader at Towers Watson.

Moving insured employees to exchanges will cost companies $2,000 per employee after the first 30 employees.

 

What companies are doing instead, according to the survey, is continuing to review the coverage they offer to see where they can save money, including by increasing employee contributions as part of a strategy that equates more spending on their part as an incentive to improve their health.

The percentage of employers offering consumer-directed health plans — a high-deductible plan eligible to be paired with a health savings account or health reimbursement arrangement — will increase to 61% in 2013 from 59% in 2012. But the big jump comes after the ACA is in place, with 80% of employers expecting to offer it by 2015. About 57% of employees will see an increase of one or more percentage points in their contribution in 2013, down from 66% in 2012, but still considered a reflection of companies’ desire to offload some costs onto their workers.

“Due to the increased costs of medical benefits and the additional burden of compliance, business leaders need to keep the pressure on to control costs, increase work force accountability and engage workers to lead a healthier lifestyle,” Abbott said.

Overall, health insurance spending per employee is expected to be $11,507 in 2013, of which employees will pay $2,596. The overall total is up 5.3% for 2013, a decline from 5.9% for 2012.

Other strategies companies are using to cut health insurance costs include discontinuing plans for retirees, with 28% saying it is very likely they would do so, up from 20% in 2011. Also, companies are looking at changing their plans to avoid paying a 40% excise tax beginning in 2018 for any plan with an aggregate value of more than $10,200 in individual coverage and $27,500 for family coverage.

Copyright 2012 American Medical Association. All rights reserved.

 

http://www.ama-assn.org/amednews/2012/09/10/bisc0910.htm 

 

New Medical Care Networks Show Savings

By ABBY GOODNOUGH
Published: September 11, 2012
The New York Times
  
 

A new model for delivering medical care, one promoted by the federal health care law, holds promise for slowing the cost of treating the sickest, most expensive patients, according to a new study.

 

The sweeping law, enacted in 2010 and upheld by the Supreme Court this summer, encourages the creation of “accountable care organizations” — networks of hospitals, doctors groups and other health care providers that collaborate to keep a defined group of patients healthier. The groups share in the savings if they meet quality and cost targets.

The study, which is being published Wednesday in The Journal of the American Medical Association, found that a predecessor to accountable care organizations achieved particular savings in caring for patients eligible for both Medicare and Medicaid.

Many of those patients have multiple, severe health conditions and are especially expensive: The nation’s nine million “dual eligibles,” as they are known, make up 15 percent of the Medicaid population but account for 39 percent of the program’s spending.

In the predecessor program, a Medicare experiment that ran from 2005 to 2010, 10 doctors groups from around the country received bonus payments if they met quality targets and achieved lower cost growth compared with Medicare spending on other patients in their region.

The study, conducted by researchers from the Dartmouth Institute for Health Policy and Clinical Practice, found that the growth in spending per “dual eligible” patient slowed by $532 a year, or 5 percent, after doctors groups joined the demonstration program.

Over all, spending on dual eligibles in the program grew at only 60 percent of the rate of the control group.

“The fact that they saved any money at all is a pretty significant finding,” said Carrie H. Colla, the study’s lead author. “It shows promise in that they did significantly improve quality while modestly improving spending.”

The study found that for dual eligibles, the savings came largely from reducing hospital stays.

Savings for the overall patient population in the experiment was more modest: Spending per patient slowed by $114 a year after the 10 doctors groups joined the demonstration program.

The groups varied significantly in how much they spent per patient and how much they slowed the growth of spending over time. The doctors group that spent the most before joining the program — the University of Michigan Faculty Group Practice, based in Ann Arbor — also saved the most, an average of $2,499 per dual eligible patient annually.

But the group that spent the least on such patients before entering the program — Marshfield Clinic, in Wisconsin — also achieved notable savings, the study found, slowing the growth of spending per dual eligible patient by an average of $987 per year.

The findings come as accountable care organizations are forming around the country. According to the Department of Health and Human Services, morethan 150 such groups now serve about 2.4 million Medicare patients.

In the predecessor program, the Medicare Physician Group Practice Demonstration, participating doctor groups were eligible for up to 80 percent of any savings they generated if they could also show improvement on 32 quality measures.

http://www.nytimes.com/2012/09/12/health/policy/medical-care-networks-show-savings-study-finds.html?_r=1

(A version of this article appeared in print onSeptember 12, 2012, on page A22 of the New York edition with the headline: New Medical Care Networks Show Savings.)

Forbes OpEd – Medicaid Gambit

 

Op/Ed
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8/23/2012 @ 12:13PM |359 views

Fools’ Gold Rush: Obamacare And The Medicaid “Opportunity”

 

Senate Passes Insurance Industry Aid Bill

(Photo credit: Mike Licht, NotionsCapital.com)

By J.D. Kleinke

You know we’ve gone through the looking glass when the hottest health care money on Wall Street is chasing Medicaid.

No, I didn’t mean Medicare, the $560 billion per year federal program for insuring the elderly that has launched a thousand IPOs. The current darling of health care investors is Medicaid, the hybrid federal-state program for insuring the poor that now dominates, and often overwhelms, state government budgets.

Last month, Wellpoint agreed to pay $4.5 billion for Amerigroup, a Medicaid managed care company, representing a nearly 50% premium over Amerigroup’s market price.  Not to be outdone, Aetna this past week purchased Coventry for $5.7 billion, which also services Medicaid populations. These deals and several others like them rumored to be in the pipeline have driven up the share prices of Amerigroup’s competitors – other Medicaid managed care companies like Centene and Molinas – in anticipation of the latest round of monkey-see, monkey-acquire deals by health insurers.

Why the gold rush into Medicaid, the poorest, toughest segment of our health care system? Are there really fortunes to be made squeezing margins out of the pittance – $4,314 per year for adults, $2,717 for children – spent on the most destitute Americans? Wellpoint, Aetna, Independence Blue Cross, and other major insurers rushing in seem to think so, for two reasons.  First, those pittances roll up: analysts estimate that the enrollment of an expected 16 million new Medicaid beneficiaries under Obamacare could generate $40 billion in potential revenue. Second, buried in Obamacare is a forced migration of as many as nine million Americans, currently eligible for both Medicare and Medicaid, from richer Medicare plans into threadbare Medicaid programs – a transfer of the most costly and complex patients worth some $300 billion in potential annual revenue.

Big numbers, big money, and big profits, right? An inflow of the uninsured poor into the nation’s most financially sssed insurance program, combined with a systemic downgrading of benefits for the poor and disabled, will surely translate into great, uncontested corporate riches. Why shouldn’t the nation’s now largest insurer spend shareholders’ cash on what amounts to 18.4 times Amerigroup’s forward earnings on forays into the most economically distressed quarters of American medicine?

Because they will fail miserably. Unless they succeed.  In which case they will be driven, by a coalition of government budget-minders and populist scolds, into failure, thanks to a political process ever more hostile to profiteering on the sick.

In normal businesses, with willing buyers and sellers and functioning marketplaces, enormous revenue opportunities do not necessarily translate into commensurate opportunities for profit. And Medicaid is about as far from a normal business as one can imagine. It is the emergency room for our worst chronic social problems. Illiteracy, drug addiction, broken families, migrant labor, illegal immigration, teen pregnancy – you name it, and Medicaid gets to deal with it. Medicaid programs attempt, mostly through heroic individual efforts, to serve a desperately needy population of the poor, chronically ill, mentally unstable, and recklessly pregnant. They do so by overworking and underpaying the nation’s most aggrieved providers, gouging drug companies, and transferring costs wherever they can to the rest of the system.

This is why states offload these programs to companies like Amerigroup and Coventry, and why many states do not want the programs expanded under Obamacare.  Medicaid is a hybrid federal/state program because the fed does not want to manage; the states manage it only because the fed blackmails with just enough money to keep them hooked.  Obamacare attempted to double-down on this blackmail by threatening to withhold all Medicaid funding to any state unwilling to accept the expansion – a provision so coercive the Supreme Court struck it down while giving the rest of Obamacare a pass.

Despite the ruling, Obamacare proceeds apace, trying to jam between 8 and 16 million more people into the same system. (The estimate varies by a factor of two because Florida, Texas, South Carolina and Louisiana, emboldened by the Court’s decision, are just saying no.)  And the horses dragging the nine million duals into Medicaid, which will entail massive disruptions in their medical care, have also left the barn. But with $340 billion in combined potential annual revenue going into play, it would be hard for companies – starved for growth and squeezed by the profit-regulation rules in Obamacare – not to rush in with their picks and shovels.

Those Pesky Implementation Details

So how might the Medicaid gold rush actually pan out? It is difficult to imagine anything but a disaster, if you know where the miners are actually headed. There is encyclopedic health services literature documenting Medicaid’s chronic economic desperation, yawning unmet medical needs, and horrific outcomes, but a more visceral illustration of the challenge comes with a simple stroll through the waiting room of a typical Medicaid provider.  On my last visit to one, I watched a morbidly obese patient die, while slumped over in his wheelchair, among the 30 patients lined up that morning to see the doctor.  It took that doctor almost ten minutes to find his way to the waiting room to declare the patient dead, and an hour for the paramedics to show up and haul him away.

Such human misery, multiplied by tens of millions of people, rolls up into a bureaucratic colossus of breathtaking complexity. Running a Medicaid program involves coping with a jungle of paperwork, cacophony of regulations and, worst of all, sanctimony in nearly every conversation with every stakeholder. It requires constant vigilance against scam clinics, crooked providers, rogue labs, pill mills, vaporware vendors, and a scuzfest of health care bottom-feeders.  A successful day in the Medicaid “business” is measured not by goals achieved but catastrophes averted.  I have been involved in restructuring one of the Medicaid disasters the commercial health plans are suddenly so hellbent on turning into shareholder gold; from under every rock we rolled over, out would crawl something slimy, and its lawyer.

Wellpoint, Aetna, Independence, and the other insurers rushing into this business no doubt believe they have a magic formula for turning this misery into a profitable growth engine.  But such growth cannot come from the top-line: the federal and state governments funding Medicaid are already under intense political pressure to reduce deficits and spending, while expanding coverage, meaning total funding available per Medicaid enrollee – and the “duals” switched from Medicare to Medicaid – will inevitably shrink, fast. As a result, the profits needed to justify these acquisitions and the ongoing tie-up of capital needed to support them must come from cost-takeouts, from the squeezing of the Medicaid turnip.

The insurers have obviously convinced themselves there is much in the turnip to squeeze. That may certainly be true for the duals, who could benefit from coordinated case management and the other bells and whistles of “managed care.” But the real money will come in the form of arbitrage margins, as the duals are switched to Medicaid doctors and hospitals, who are paid a pittance compared with Medicare. This will work fine – for a time – if these “duals” happily tow the line and change doctors.  But history shows otherwise. People do not like to have their benefits downgraded, and they do not like  being forced to switch to cheaper doctors, especially if there are no doctors to switch to – overwhelmingly the case in Medicaid. Their doctors’ lobbyists may also have something to say about it.

As for the general Medicaid population, the single greatest medical demand placed on the program, in terms of volume if not dollars, is pregnancy and childbirth. It is the reason for half of all Medicaid hospitalizations; seven of the ten most common procedures performed during those hospitalizations are related to pregnancy, childbirth, and newborns. If cost-takeouts are the only road to profitability, are the insurers prepared to deal with pesky little matters like the public funding of birth control, abortion, home births and c-sections, i.e., with arguably health care’s ugliest culture wars?  My own experience working with insurers on the least incendiary of these issues – the silent epidemic of c-sections – is not encouraging.  C-sections account for more than 30 percent of all deliveries in the US, at roughly 1.5 times the average costs of a normal delivery, when the medically indicated rate is easily less than half that.

This would be the first place for an insurer to step in to reduce Medicaid costs, yes?  One little technical problem: aside from captive provider systems with electronic medical records like Kaiser, not a single insurer I know of in the US has any ability to affect this scandalously high rate of often unnecessary, always expensive, high-volume surgery.  Two major insurers have admitted to me that they have no systematic way of knowing who in their population of millions of covered women are even pregnant, until after they have delivered, the probably unnecessary c-section has been done, and the claims are coming in.  This might be an example of why the insurers are acquiring the Medicaid managed care companies – because they may have this expertise.  If so, no one is talking about it, because companies cannot even bring up the subject of pregnancy and childbirth among the poor without triggering the worst landmines in the health care policy debates, as we have witnessed since the daylighting of the Obamacare birth control mandate.

No Good Implementation Goes Unpunished

Let’s give the Medicaid gold rushers the benefit of the doubt, and assume they pull off something like this. A few managed care type miracles, they lower costs for Medicaid patients without actually harming them and, in the case of unnecessary surgeries, actually help some of them.

Imagine also they pull off the trick of shuttling the “duals” from Medicare to Medicaid.  These highly motivated patients and their doctors somehow don’t scream bloody murder, and the insurers earn arbitrage margins on the switch. How long will financially stressed governments fund these margins, before putting the turnip squeeze on the insurers themselves? For those insurers who find Medicaid gold, what happens next? They will be vilified by the public as corporate, profiteering, care-denying murderers of the poor, and their margins will be mowed down with the stroke of the legislative pen.

Every health care sector has been on the receiving end of this at some point – hospitals, dialysis, home health, the list goes on – usually right after its own gold rush.  The government programs that represent an ever larger share of health care purchasing in the US do not overtly regulate profitability – that would be transparent and at least manageable. Instead they regulate profits implicitly, line-item by line-item via reimbursement adjustments, selective and punitive enforcements of providers, a whole gamut of bureaucratic tricks designed to avoid honest political debate about the role of money and medicine.

The health insurers already got a face full of cold water with this under Obamacare: new administrative cost and profit margin regulations set at completely arbitrary numbers. Those numbers will appear generous when the Medicaid gold proves to be nothing more than a very big flash in a very broken pan.

J.D. Kleinke is a Resident Fellow of the American Enterprise Institute and a former health care executive.  His latest book is Catching Babies, a novel about the training of obstetrician/gynecologists.

Obama Rated Higher in Trust on medicare

August 23, 2012

In Poll, Obama Is Given Trust Over Medicare

By and DALIA SUSSMAN

NY Times

The Romney-Ryan proposal to reshape Medicare by giving future beneficiaries fixed amounts of money to buy health coverage is deeply unpopular in Florida, Ohio and Wisconsin, according to new polls that found that more likely voters in each state trust President Obama to handle Medicare.

The Medicare debate was catapulted to the forefront of the presidential campaign this month when Mitt Romney announced that his running mate would be Representative Paul D. Ryan of Wisconsin, who is perhaps best known for proposing a budget plan, supported by Mr. Romney, to overhaul Medicare to rein in its costs.

After more than a week of frenzied campaigning on the issue, Medicare ranks as the third-most crucial issue to likely voters in Florida, Ohio and Wisconsin — behind the economy and health care, according to new Quinnipiac University/New York Times/CBS News polls of the three swing states. The Republican proposal to retool the program a decade from now is widely disliked.

Roughly 6 in 10 likely voters in each state want Medicare to continue providing health insurance to older Americans the way it does today; fewer than a third of those polled said Medicare should be changed in the future to a system in which the government gives the elderly fixed amounts of money to buy health insurance or Medicare insurance, as Mr. Romney has proposed. And Medicare is widely seen as a good value: about three-quarters of the likely voters in each state said the benefits of Medicare are worth the cost to taxpayers.

“On Medicare, I don’t like the Paul Ryan plan,” said Beverly McLaren, 72, an independent from St. Petersburg, Fla., who said in a follow-up interview that Medicare worked well for her and that she planned to vote to re-elect Mr. Obama. “I can’t see how it will help at all, and we’ll have more out-of-pocket expenses, and I’m not really clear how it will work.”

About 60 percent of independent voters in the three states support keeping Medicare as it is today, as do at least 8 in 10 Democrats. Republicans are closely divided on the issue in Florida and Ohio, but in Wisconsin, Mr. Ryan’s home state, a majority of Republicans support changing it along the lines he has proposed.

The polls — the first in this series of swing-state surveys taken since Mr. Ryan joined the Republican ticket — showed that at least in Mr. Ryan’s home state, he may be helping Mr. Romney. A majority of likely Wisconsin voters said they approved of the way Mr. Ryan has handled his job in Congress, and 31 percent said his selection made them more likely to vote for Mr. Romney, while 22 percent said it made them less likely to do so. The race appears to have tightened a bit in both Florida and Wisconsin in recent weeks.

In Florida and Wisconsin, where Mr. Obama had led Mr. Romney by six percentage points in polls conducted before the selection of Mr. Ryan, the race is essentially tied. Mr. Obama is ahead in Florida by 49 percent to 46 percent and in Wisconsin by 49 percent to 47 percent — differences within the polls’ margin of sampling error of plus or minus three percentage points. Mr. Obama retains a six-point advantage in Ohio, where he leads Mr. Romney 50 percent to 44 percent, unchanged from last month’s survey.

The polls were largely conducted before the uproar over remarks on rape and abortion made by a Republican Senate candidate in Missouri, Representative Todd Akin, which officials in both parties agree could alter the dynamic of the race, especially among women. Mr. Obama enjoys solid support of a majority of women in each of these three states, the surveys found, but in Wisconsin his healthy lead among women has narrowed since the last poll and now trails the levels of the 2008 election, when he won the state.

The polls’ findings on Medicare underscore the risk Mr. Romney took when he chose Mr. Ryan to be his running mate. Mr. Ryan rose to prominence among conservatives who lauded his willingness to propose unpopular measures to balance the budget and cut the rising costs of Medicare — costs officials in both parties agree are on an unsustainable path. But while the polls found that Mr. Romney enjoyed a wide advantage in all three states on the question of who is better equipped to tackle the budget deficit, it found that he lagged on other questions voters feel strongly about — including who is better equipped to handle health care, Medicare and foreign policy. Some voters give them credit for campaigning on a politically contentious issue.

“It may be political suicide, but at least Romney and Ryan are willing to stand up and say we can’t keep shoveling money into this program and other programs like this,” said Michael Behnke, 59, an independent from Solon, Ohio.

When it comes to the running mates, Mr. Ryan comes out ahead with independents. On balance, they feel more favorable toward Mr. Ryan but have a more negative view of Vice President Joseph R. Biden Jr., who has drawn criticism in recent days for saying that Mr. Romney’s policies would unchain the financial sector and “put y’all back in chains.” But many voters in Florida and Ohio said they did not yet know enough about Mr. Ryan to form an opinion — and many in all three states said the choice of running mate would have no impact on their votes.

The polls were conducted by telephone (landline and cellphones) from Aug. 15 through Tuesday among 1,241 likely voters in Florida, 1,253 likely voters in Ohio and 1,190 likely voters in Wisconsin. All three are states Mr. Obama won, but where Republicans have since made gains in state and local elections.

Mr. Romney has taken pains to stress that his Medicare plan would not change the benefits for people 55 or over. But voters over 55 have strong feelings about it, including in Florida, the electoral-vote-rich state where Republicans will hold their convention next week.

Jim Ryan, 75, a retired executive from Bradenton, Fla., who is an independent, said it was an important issue because he and his wife were on Medicare.

“We’re enjoying the benefits now, and the Paul Ryan program of making it into a voucher system would change things,” he said. “I know it’s not intended to apply to people in our age group, but I’m concerned about the future. I think it’s a wonderful program, and I’ve got middle-aged children and I don’t want to see the program destroyed. It’s probably one of the best programs sponsored by the federal government that we’ve ever had. It does have to be made fiscally sound, but there are ways to do that without destroying the whole concept or the substance of it.”

Mr. Romney has been attacking Mr. Obama for counting on $716 billion in Medicare savings to help pay for his health care law — savings that Mr. Ryan also counted on in his budget plan but which Mr. Romney has promised to restore. The poll underscored how unpopular deep cuts to Medicare are.

Only about a tenth of the voters in each state said they would support major reductions in Medicare spending to reduce the federal deficit. Nearly half of the voters in each state said they would support minor reductions, and about a third said they would not support any reductions at all.

Reporting was contributed by Marjorie Connelly, Allison Kopicki, Marina Stefan and Megan Thee-Brenan.

Salary Caps too Low for Medicaid?

August 14, 2012 9:39 PM

Is a $5,000 salary too much for Medicaid?

(AP) MIAMI – Sandra Pico is poor, but not poor enough.

She makes about $15,000 a year, supporting her daughter and unemployed husband. She thought she’d be able to get health insurance after the Supreme Court upheld President Barack Obama’s health care law.

Then she heard that her own governor won’t agree to the federal plan to extend Medicaid coverage to people like her in two years. So she expects to remain uninsured, struggling to pay for her blood pressure medicine.

“You fall through the cracks and there’s nothing you can do about it,” said the 52-year-old home health aide. “It makes me feel like garbage, like the American dream, my dream in my homeland is not being accomplished.”

Many working parents like Pico are below the federal poverty line but don’t qualify for Medicaid, a decades-old state-federal insurance program. That’s especially true in states where conservative governors say they’ll reject the Medicaid expansion under Obama’s health law.

In South Carolina, a yearly income of $16,900 is too much for Medicaid for a family of three. In Florida, $11,000 a year is too much. In Mississippi, $8,200 a year is too much. In Louisiana and Texas, earning more than just $5,000 a year makes you ineligible for Medicaid.

Governors in those five states have said they’ll reject the Medicaid expansion underpinning Obama’s health law after the Supreme Court’s decision gave states that option. They favor small government and say they can’t afford the added cost to their states even if it’s delayed by several years. Some states estimate the expansion could ultimately cost them a billion dollars a year or more.

Many of the people affected by the decision are working parents who are poor — but not poor enough — to qualify for Medicaid.

Republican Mitt Romney’s new running mate, conservative Wisconsin congressman Paul Ryan, has a budget plan that would turn Medicaid over to the states and sharply limit federal dollars. Romney hasn’t specifically said where he stands on Ryan’s idea, but has expressed broad support for his vice presidential pick’s proposals.

Medicaid now covers an estimated 70 million Americans and would cover an estimated 7 million more in 2014 under the Obama health law’s expansion. In contrast, Ryan’s plan could mean 14 million to 27 million Americans would ultimately lose coverage, even beyond the effect of a repeal of the health law, according to an analysis by the nonpartisan Kaiser Family Foundation of Ryan’s 2011 budget plan.

For now, most states don’t cover childless adults, but all states cover some low-income parents. The income cutoff, however, varies widely from state to state.

Most states cover children in low-income families. Manuel and Sandra Pico’s 15-year-old daughter is covered by Medicaid. But the suburban Miami couple can’t afford private insurance for themselves and they make too much for Florida’s Medicaid.

Manuel Pico, a carpenter, used to make more than $20,000 a year, but has struggled to find work in the last three years after the real estate market collapsed. He occasionally picks up day jobs or takes care of the neighbor’s yard. Sandra Pico would like to work full time, but can’t afford to pay someone to watch her 34-year-old sister, who has Down syndrome.

“No matter how hard I work, I’m not going to get anywhere,” Sandra Pico said. “If you’re not rich, you just don’t have it.”

In San Juan, Texas, 22-year-old Matthew Solis makes about $8,700 a year — too much to qualify for Medicaid in that state. Solis, a single father with joint custody of his 4-year-old daughter, said he works about 25 hours per week at a building supply store making minimum wage and is a full-time college student at the University of Texas-Pan American. He aspires to be a school counselor.

He recently sought medical care for food poisoning, visiting a federally funded clinic. But he doesn’t see a doctor regularly because he can’t afford private insurance. The new health law allows young adults to remain on their parents’ insurance until age 26. But that doesn’t help Solis, whose father is uninsured and whose mother died of leukemia when he was 8.

“I voted for him (Obama) because he promised we would have insurance,” Solis said. “I’m pretty upset because I worked for Obama and I still don’t have coverage.”

His governor, Rick Perry, like Pico’s governor, Rick Scott, is rejecting the Medicaid expansion. So Solis too is out of luck unless his circumstances dramatically change.

In all but one of the states where governors are rejecting or leaning against the expansion, the income level that disqualifies a parent from Medicaid is below the federal poverty line. Only in New Jersey, where Gov. Chris Christie has said he’s leaning against the expansion, is Medicaid available to parents with incomes at the poverty line and slightly above. New Jersey will cover a parent making $24,645 in a family of three.

Most states base Medicaid eligibility for parents on household income and how it compares to the federal poverty level, which was $18,530 for a family of three in 2011, the year being used for easier state-by-state comparisons.

In Louisiana, the eligibility cutoff for a working parent is 25 percent of federal poverty, or $4,633 for a family of three. In Nevada, it’s 87 percent of the federal poverty level, or $16,121 for a family of three.

That’s been the range in states where governors are likely saying no to expanded Medicaid.

In contrast, states where governors have said they’ll expand Medicaid are more generous with working parents. The Medicaid eligibility cutoff ranges in those states from Washington’s $13,527 to Minnesota’s $39,840.

To be sure, some states with generous coverage for parents have been forced to cut back. Illinois, facing a financial crisis, ended coverage last month for more than 25,000 working parents. Even so, the state still covers working parents with incomes slightly higher than the poverty line.

The national health law’s Medicaid expansion would start covering all citizens in 2014 who make up to roughly $15,400 for an individual, $30,650 for a family of four.

The federal government will pay the full cost of the Medicaid expansion through 2016. After that, the states will pick up 5 percent of the cost through 2019, and 10 percent of the cost thereafter.

Why would a governor say no?

These state leaders are in favor of smaller government. In principle, they don’t want the federal government to expand — even if that expansion would help their own citizens. Also Medicaid is costly, taking a huge bite out of budgets already. And they don’t want to be on the hook for paying any more of the tab even if it’s years down the road.

“We don’t need the federal government telling us what to do when it comes to meeting the needs of the citizens of our states,” Florida Gov. Rick Scott wrote recently in an opinion piece for U.S. News and World Report. “And we don’t need Washington putting states on the hook for future budget obligations.”

Also, many conservatives view Medicaid as a wasteful, highly flawed program, akin to no health coverage. Many doctors across the country won’t treat Medicaid patients because the payments they receive are so low.

When the Supreme Court ruled that states could opt out of the health law’s Medicaid expansion, it raised the chances for inequity at a time when more Americans have fallen from the middle class into poverty, said Isabel Sawhill, a senior fellow at the Brookings Institution.

“Why should a sick person in Connecticut have access to health care when they don’t in Mississippi and Texas?” Sawhill asked. “We really do have a very high level of poverty as a result of the recession. And the safety net is weaker than ever.”

Medicaid, the nation’s single largest insurer, is a state and federal program created in 1965 as a companion program to welfare cash assistance to single parents. Today, the elderly and disabled cost nearly 70 cents of every Medicaid dollar, not the stereotypical single mother and her children.

What’s largely unknown to many Americans is who is left out of the safety net, said Cheryl Camillo, a senior researcher at Mathematica Policy Research. “A huge chunk of the populace is not covered, even by Medicaid,” she said.

The political rhetoric during a presidential campaign focuses on the middle class and leaves the uninsured working poor largely invisible, said Rand Corp. researcher Dr. Art Kellermann.

“We hear a lot of talk about unemployment and the aspirations of middle-class Americans. But we don’t hear about the consequences of unemployment and the consequences of the collapsing middle class,” Kellermann said. Losing health insurance is one of those consequences.

“It’s like the public just doesn’t want to believe anything else until it hits home,” he said, “Until it’s their own child, brother or parent that got laid off when they were 58, until then, it’s not real.”

 

Bloomberg Businessweek – Ryan Medicaid Plan

The other Paul Ryan plan: $800B in Medicaid cuts

By By Ricardo Alonso Zaldivar on August 15, 2012

WASHINGTON (AP) — There’s another Paul Ryan plan for health care, a fundamental change in caring for the poor and disabled that would affect many more people than the Medicare overhaul the GOP vice presidential candidate is best known for.

Under the Wisconsin congressman’s Medicaid plan, states would take over the program. At the same time, Ryan’s budget would reduce projected federal spending on Medicaid by about $800 billion over 10 years, dramatically shrinking it as a share of the national economy.

Medicaid serves about 60 million people, roughly 10 million more than Medicare. It’s a diverse population brought together by need. Most Medicaid recipients are low-income children and their mothers, but the costliest cases are severely disabled people, many of them seniors in nursing homes.

Ryan would also repeal President Barack Obama’s health care law, expected to add at least 11 million more people to Medicaid.

Ryan’s Medicaid plan is in sync with his new boss, Republican presidential candidate Mitt Romney.

“Gov. Romney … believes that states are far better positioned to design programs that effectively serve those in need,” said campaign spokeswoman Andrea Saul.

But no matter who runs Medicaid, such cuts would result in millions of vulnerable people losing health insurance, according to advocates for the poor and some nonpartisan economic analysts.

“Medicaid is already a very lean program,” said Edwin Park of the Center on Budget and Policy Priorities, which advocates for low-income people. “It is not a program where you can magically glean huge efficiencies by just devolving it to the states. The only way to compensate for funding reductions of this magnitude would be to institute deep, damaging cuts to beneficiaries and the health care providers who serve them.”

Bring it on, says Wisconsin Health Secretary Dennis Smith, who oversees Medicaid in Ryan’s home state. Smith, who works for Republican Gov. Scott Walker, says states can cut costs without gutting services by running Medicaid more efficiently.

“Everybody agrees that there is excess cost in the health care system, so by golly, give us the flexibility to address it, and we will,” said Smith. “We can serve the people on Medicaid with the adjustments the Ryan budget. We can make that work.”

For example, Wisconsin is now charging some low-income adults a modest monthly premium for Medicaid, tapping a new funding source to pay for valuable benefits, Smith said. And the state is looking for ways to help frail elderly people keep living at home, avoiding the costly alternative of a nursing home.

Growing enrollment has turned Medicaid into a big share of state budgets, and since Washington sets many of the rules, the program is a source of constant tension between federal and state governments. On average, the federal government pays about 60 percent of Medicaid costs, and states cover the rest. The Supreme Court recently gave some latitude to states chafing at Obama’s health care law, saying they are free to opt out of its Medicaid expansion.

Obama has largely shielded Medicaid from cuts in budget negotiations with Congress. But his administration has proposed new ways to allocate funding that could be used to dial back the federal share.

Ryan’s plan goes beyond tweaking. It would essentially rip up the Medicaid manual and start all over again. States would get a lump sum from Washington, a “block grant” indexed to reflect population growth and inflation. The idea has governors split along party lines.

Ryan’s Medicare plan, shifting future retirees to private insurance, would phase in over a decade or more. The Medicaid changes would come much more rapidly. The proposal has not been fleshed out, leaving many unanswered questions. For example:

—What happens if a state’s economy tanks?

Under current law, the federal Medicaid share is pegged to program enrollment, not population growth, said John Holahan, director of the Health Policy Center at the nonpartisan Urban Institute. That means federal funding increases when the Medicaid rolls swell. But under Ryan’s plan, “there are no provisions to automatically deal with recessions,” said Holahan. “The demand for Medicaid goes up at the same time state revenue is going down.”

—Would low-income and disabled people still have a legal right to coverage?

Converting Medicaid into a block grant would end the current right to coverage under federal law, and it remains unclear what rights could be preserved. Most analysts say states would insist on the flexibility to reduce their Medicaid rolls. The Urban Institute estimates that between 14 million and 27 million people would lose coverage because of Ryan’s spending restrictions.

—What sorts of safeguards would remain in place for seniors in need of nursing home care?

Although frail elderly people must spend down most of their savings before they can qualify for Medicaid, a federal law shields spouses from becoming impoverished. It’s unclear what would take its place.

Supporters of state control say governors and legislatures are closer to the people and would not harm their own constituents.

Back in Ryan’s state, the jury is still out.

Medicaid covers nearly 1 in 5 Wisconsin residents, and hospitals have a major stake in the outcome. Joanne Alig, senior vice president for policy with the Wisconsin Hospital Association, says they would need to know more about the plan to reach conclusions.

“While I think we are supportive of looking at alternatives to the Medicaid status quo, the devil’s in the details,” she said.

NY Times – Medicare Issue Hot in Campaigns

August 14, 2012

Two-Way Jabs on Medicare Recast Races for Congress

By

WASHINGTON — In one tight Florida House race, a hastily assembled TV commercial to begin airing Wednesday takes aim at a top target of Democrats, highlighting his votes “to end Medicare as we know it.”

Republicans in Montana are advertising on behalf of their Senate candidate, noting his stance against a Republican plan “that could harm the Medicare program.” House Republican strategists are advising their lawmakers to try to stay on the offensive over Medicare and steer clear of words like privatization.

The fight over Medicare, the popular federal health care program for older Americans, is rapidly intensifying in House and Senate races around the nation after the selection of Representative Paul D. Ryan as the Republican vice-presidential candidate. Congressional Democrats and some analysts say that development could transform the fight for control of Congress, given his role as the author of a House-approved budget plan that would reshape Medicare.

“A House budget plan is a House budget plan,” Senator Patty Murray of Washington, the chairwoman of the Democratic Senatorial Campaign Committee, said Tuesday. “But all of the sudden the architect and definer of that has the potential of sitting in the White House, and that is really frightening to people.”

Despite political anxiety expressed privately by some Republican strategists about Mitt Romney’s choice of Mr. Ryan, other top Republicans say that they welcome the fight over Medicare and that they believe they can win a national debate over the future of entitlement programs. They intend to paint the Democratic Party as the one putting Medicare at risk by failing to come up with a plan to keep it solvent as a wave of baby boomers approaches retirement age.

Mr. Romney said Tuesday that he would, if president, restore Medicare cuts that both President Obama and Congressional Republicans have backed and unveiled a new campaign advertisement trying to drive home that point.

“Paul Ryan and Republicans are the only ones who have stepped up with proposals,” said Senator John Cornyn of Texas, head of the National Republican Senatorial Committee. “These issues were going to come up anyway, and you might as well have your best and most articulate spokesman on the field making the case for it, and that is Paul Ryan.”

Mr. Ryan’s new prominence has abruptly thrust Medicare into the top tier of issues, but it was always going to be a theme in the 2012 House and Senate elections and was already playing a role in advertising.

Democrats had long intended to assault Republicans who voted for the Ryan budget in 2011 and 2012 and were trying to find a way to figuratively put Mr. Ryan on the ballot with his colleagues. Now Mr. Ryan will literally be on the ballot, and top Democratic strategists say that in picking him, Mr. Romney has given Medicare a huge boost as a driving issue that could lift Democrats in dozens of close races.

“Mitt Romney has given us a lot to work with,” said Representative Steve Israel of New York, chairman of the Democratic Congressional Campaign Committee. “It was becoming challenging to try to nationalize the Ryan budget, and Mitt Romney just handed that to us.”

House Democrats moved quickly on Tuesday to try to cash in. In a high-profile South Florida race, the Democratic candidate, Patrick Murphy, prepared a new ad against the Republican incumbent, Allen B. West, that highlighted Mr. West’s two votes for the Ryan budget while asserting that Mr. Murphy would “fight for seniors, protect Medicare.”

While the new commercial does not specifically mention Mr. Ryan, strategists said it was fashioned to capitalize on his joining the race for the White House. It is also the leading edge of what is likely to be a flurry of ads, Web activity and aggressive political advocacy as the two parties compete to shape the narrative on Medicare.

In addition to helping bankroll Mr. Murphy’s ad, the Congressional committee began automated phone calls in the districts of 50 Republican incumbents who voted for Mr. Ryan’s budget, which would turn Medicare into a voucher program for future retirees. In Nevada, a labor group is buying online ads that say the Romney-Ryan ticket would drive up costs for older Americans.

As Democrats pushed the idea of a political windfall, top Republicans say they believe the worry about Mr. Ryan is overheated. They say they were already bracing for a Medicare line of attack and are more than ready for it.

“We’ll take any opportunity to talk about Obamacare and the Medicare cuts that were included in it,” said Paul Lindsay, a spokesman for the National Republican Congressional Committee, who said that Republicans had learned how to contend with the issue after having debated it for more than two years already.

In a private message to candidates, House Republican leaders sought to allay any concern by providing material on how to respond to inquiries on Medicare, suggesting that candidates make the case that Democrats have their own lightning rod of a running mate: the new health care law.

The message also advises Republicans to choose their words carefully and emphasize “strengthen” and “protect” over phrases like “every option is on the table.”

Despite the Republicans’ confidence in their ability to counter the Democrats, the Senate race in Montana offered evidence that some party leaders recognize that the Ryan budget could be a liability.

The state party there paid for an advertisement on behalf of Representative Denny Rehberg, a Republican who is in a close race with Senator Jon Tester, a Democrat. It lauds Mr. Rehberg for his votes against the Ryan budget, a stance that the advertisement said showed his independence in partisan Washington.

The ultimate impact of the Ryan pick on Congressional races will become clearer in the days ahead.

“Certainly more Democrats are more enthusiastic than they were last week,” said Jessica Taylor, a senior analyst for the nonpartisan Rothenberg Political Report. “But whether it moves a ton of races, we are going to have to wait and see.”

Michael D. Shear and Sarah Wheaton contributed reporting from New York.