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U.S. Centers for Medicare & Medicaid Services

Vaccine mandate for health care workers blocked

I’d say this is getting ridiculous, but we’re well past that point.

A federal judge on Monday blocked President Joe Biden’s administration from enforcing a coronavirus vaccine mandate on thousands of health care workers in 10 states that had brought the first legal challenge against the requirement.

The court order said that the federal Centers for Medicare & Medicaid had no clear authority from Congress to enact the vaccine mandate for providers participating in the two government health care programs for the elderly, disabled and poor.

The preliminary injunction by St. Louis-based U.S. District Judge Matthew Schelp applies to a coalition of suing states that includes Alaska, Arkansas, Iowa, Kansas, Missouri, Nebraska, New Hampshire, North Dakota, South Dakota and Wyoming. All those states have either a Republican attorney general or governor. Similar lawsuits also are pending in other states.

The federal rule requires COVID-19 vaccinations for more than 17 million workers nationwide in about 76,000 health care facilities and home health care providers that get funding from the government health programs. Workers are to receive their first dose by Dec. 6 and their second shot by Jan. 4.

The court order against the health care vaccine mandate comes after Biden’s administration suffered a similar setback for a broader policy. A federal court previously placed a hold on a separate rule requiring businesses with more than 100 employees to ensure their workers get vaccinated or else wear masks and get tested weekly for the coronavirus.

Biden’s administration contends federal rules supersede state policies prohibiting vaccine mandates and are essential to slowing the pandemic, which has killed more than 775,000 people in the U.S. About three-fifths of the U.S. population already is fully vaccinated.

But the judge in the health care provider case wrote that federal officials likely overstepped their legal powers.

“CMS seeks to overtake an area of traditional state authority by imposing an unprecedented demand to federally dictate the private medical decisions of millions of Americans. Such action challenges traditional notions of federalism,” Schelp wrote in his order.

That ruling doesn’t affect Texas, but this one does.

A federal judge on Tuesday blocked the Biden administration’s COVID-19 vaccination mandate for health care workers from going into effect nationwide next week after Texas and other states challenged the order.

Louisiana Western District U.S. Judge Terry Doughty’s ruling follows the same decision on Monday from Missouri U.S. District Judge Matthew Schelp. However, Schelp’s ruling applied for only 10 states.

Doughty wrote in his decision that the mandate exceeds the Biden administration’s authority.

“If human nature and history teach anything, it is that civil liberties face grave risks when governments proclaim indefinite states of emergency,” Doughty wrote.

I Am Not A Lawyer, and I couldn’t find any commentary out there about this, but just knowing that it was two Trump-appointed judges who made these rulings makes me look at them with extreme skepticism. (There are some other reasons for that, as the Daily Kos story indicates. I still want to see some serious lawyers weigh in on it.) The willingness of so many people to put the lives of so many other people in danger just boggles my mind.

On the moderately positive side, there was this.

A judge in Galveston has denied a bid from a group of federal workers seeking an injunction to halt enforcement of the White House’s COVID-19 vaccination mandate, saying they had natural immunity from having been infected with the virus.

John J. Vecchione, senior litigation counsel for the New Civil Liberties Alliance in Washington, D.C., said his team argued it was “arbitrary and capricious” to require vaccinations across the board for all federal employees, because this particular group of workers was not any more dangerous to others than people who have been fully vaccinated. Vecchione says in court documents his clients’ immunity is “at least as robust and durable as that attained through the most effective vaccines.”

[…]

The 11 litigants include a high ranking lawyer at U.S. Immigration and Customs Enforcement from Frisco, a Navy technician from Robstown, an air traffic controller from St. Cloud, Fla. , a Georgia-based veterinary specialist from the Department of Agriculture, a special agent with the Secret Service from Springfield, Va. and a supervisory air marshal with Transportation Security Administration in Palos Verdes, Calif. .

The suit is directed at Dr. Anthony Fauci, others on the COVID response task force and representatives of other federal agencies tasked with enforcement or supervision of the mandate. The deadline for vaccinations was Nov. 22 and enforcement was set to begin some time after Nov. 29.

U.S. District Judge Jeffrey V. Brown denied the workers request for a temporary injunction, saying they did not face irreparable harm if they complied with the mandate and they were unlikely to win their case on the merits. He noted that all but one of the plaintiffs were pursuing religious exemptions that would allow them to avoid the vaccine. The worker who did not seek an exemption works for ICE; the judge said the civil liberties lawyers had probably erred in failing to sue that agency.

Any win for sanity at the district court level feels like it’s written on sand these days, but I’ll take what I can get. Roy Edroso has more.

The nursing home vaccination mandate

This just seems obvious to me.

President Joe Biden announced on Wednesday that he is directing all nursing homes to require their staff be vaccinated against Covid-19 in order to continue receiving Medicare and Medicaid funding.

Biden said he is directing the Department of Health and Human Services to draw up new regulations making employee vaccination a condition for nursing homes to participate in Medicare and Medicaid. The decision on nursing home staff represents a significant escalation in Biden’s campaign to get Americans vaccinated and the tools he is willing to use, marking the first time he has threatened to withhold federal funds in order to get people vaccinated.

“Now, if you visit, live or work at a nursing home, you should not be at a high risk of contracting Covid from unvaccinated employees. While I’m mindful that my authority at the federal government is limited, I’m going to continue to look for ways to keep people safe and increase vaccination rates,” the President said during a speech at the White House.

[…]

The move comes as the more transmissible Delta variant now accounts for 99% of Covid-19 cases in the United States and as data shows a link between low vaccination rates in certain nursing homes and rising coronavirus cases among residents.

The Delta variant has spurred a jump in daily new cases from a low of 319 on June 27 to nearly 2,700 on August 8, according to Centers for Medicare & Medicaid Services. Many are in facilities in areas with the lowest staff vaccination rates.

In the seven states in which less than half of nursing home staff is vaccinated, weekly cases were 7.9 times higher in the week ending August 1 than they were in the week ending June 27. Meanwhile, in states that have vaccinated a larger share of staff than average (more than 60%), cases reported in the week ending August 1 were only three times higher than cases reported in the last week of June.

The new regulations could go into effect as early as next month, but Johnson said the CMS will work with nursing homes, employees and their unions to ramp up staff vaccinations before the regulations go into effect.

About 1.3 million people are employed by the more than 15,000 nursing homes that participate in Medicare and Medicaid. Some 62% of those workers are vaccinated nationwide, according to CMS data, but the figure ranges from 44% to 88% depending on the state.

“We have seen tremendous progress with low Covid rates within the nursing home population and I think we’re seeing signs that it is starting to tip the other direction. We don’t want to go backwards,” said Jonathan Blum, CMS’ principal deputy administrator.

Blum said CMS officials are “confident we have the legal authority” to implement the new regulation, noting that the law allows CMS to take action as it relates to the health and safety of nursing home residents.

As the story notes, this came a day after Biden directed the Education Department to get involved in the mask mandate fight. You would think, given how devastating the first wave of COVID was to the residents of nursing homes, that their staffers would be highly vaccinated as well, but you would be wrong.

Nationwide, most of the elderly and vulnerable in long-term care facilities have taken the coronavirus vaccine, but many of the staff caring for them have refused it. The federal program responsible for bringing vaccines to the vast majority of nursing homes and similar settings inoculated roughly half of long-term-care workers in the nation, and in some states a much slimmer percentage, as of March 15, according to new data from the Centers for Disease Control and Prevention provided to the Center for Public Integrity.

In seven states and the District of Columbia, the program vaccinated less than a third of staff members.

Now the federal program is winding down in the coming days, leaving states and facilities to figure out how to vaccinate the remainder of workers in settings where COVID-19 has already taken a heavy toll.

Though they represent a tiny fraction of the American population, long-term-care residents made up 34% of the nation’s COVID-19 deaths as of March 4, according to the Covid Tracking Project. Low vaccination rates among staff at these facilities mean that workers continue to have greater risk of contracting COVID-19 themselves or passing the virus to their patients, including residents who can’t be inoculated for medical reasons. Low staff uptake can also complicate nursing homes’ attempt to reopen their doors to visitors like Caldwell, who are striving for some sense of normalcy.

“Going into it, we knew it was going to be a problem,” said Ruth Link-Gelles, who led the team at CDC working on the federal initiative that’s now closing up shop, the Federal Pharmacy Partnership for Long-Term Care Program.

She cited past years’ low vaccination rates among long-term-care workers for diseases such as the flu. “We were disappointed, but I don’t think anyone was shocked to see the low uptake. … There is a stubbornly large portion of the population that really doesn’t want to get vaccinated, and we have a lot of work to do generally and in this community in particular.”

Federal agencies and states have poured resources into a #GetVaccinated educational campaign, hosting listening sessions, live chats and virtual town halls for long-term-care staff to get their questions answered.

In spite of all these efforts, many workers are reluctant to take the shots because they don’t trust information about the vaccines’ safety or they don’t wish to be among the first to take them, experts said.

“There are many reasons to blame nursing homes and the federal government,” said David Grabowski, a professor of health care policy at Harvard Medical School who studies long-term care. “We knew this coming in — that this was a group that was not very trusting of leadership and frankly not very trusting of the vaccine so it was going to take some work in terms of building that trust.”

That story was from late March, so things may be better by now. According to the map embedded in this story, as of that time about 54% of the long-term care workers in Texas who have been vaccinated got their shots through this federal program. But as usual, the overall story in Texas is not great.

The number of nursing homes across the state with at least one active COVID-19 case has shot up nearly 800% in the past month — while nearly half of nursing home employees in Texas remain unvaccinated.

Nursing home residents were among the hardest hit by COVID-19 last year as the virus tore through facilities at an alarming rate. More than 400 Texas nursing home residents died during a single week in August 2020; since the pandemic began, 9,095 have died after contracting COVID-19, according to the Texas Health and Human Services Commission. As of Aug. 11, that’s 17% of the state’s COVID-19 deaths.

To slow the virus’s spread, Gov. Greg Abbott shut down nursing home visitation in March 2020, then eased those restrictions five months later for facilities that didn’t have active cases in the previous two weeks. HHSC’s current visitation guidelines for nursing homes require visitors to wear a mask at all times and limits visitation to no more than two “essential caregivers” per resident.

But after seeing infections remain relatively low in recent months, the state’s more than 1,200 nursing homes are seeing a new wave of infections as COVID-19 cases explode around the state, driven by the highly contagious delta variant:

  • The number of Texas nursing homes with active COVID-19 cases has risen by 773% in the past month, from 56 in mid-July to 489 on Aug. 11. That’s still well below the peak in January, when more than 900 facilities had at least one active case.
  • Deaths are increasing as well. From July 21 to Aug. 11, 84 nursing home residents died from COVID-19, compared to seven deaths during the four-week period before.
  • Roughly 76% of nursing home residents in Texas have been fully vaccinated, putting the state 46th nationally. The national average is 82%.

But the current surge in nursing home cases hasn’t triggered renewed restrictions by the state.

“We continually assess what actions are necessary to keep people safe in the facilities we regulate,” HHSC spokesperson Helena Wright-Jones said in a written statement.

Meanwhile, just over half — 56% — of nursing home staff have been fully vaccinated, below the national average of 59%, which puts Texas 33rd nationally for nursing home staff vaccination rates.

In other words, the usual indifference from state government and general mediocrity, which puts a whole lot of people at risk. What do the nursing homes have to say for themselves?

Kevin Warren, the president and CEO of the Texas Health Care Association, whose members include both for-profit and nonprofit long-term health care facilities, said nursing homes are hesitant to require staff to be vaccinated because they are fearful of losing employees who might look for other jobs that don’t require vaccinations.

“Right now, we have a severely stretched workforce,” Warren said. “And when we see this surge occurring again, the stress and the emotional toll it places on staff and others that are in the building, the concern is: ‘If I put this vaccine mandate on, am I potentially going to lose staff?’”

The percentage of nursing home staffers who are unvaccinated is similar to the general population, Warren added, “so let’s not set them out to the side.”

Except they’re in close contact with the most vulnerable people in the state, and not enough of them are vaccinated, either. The DMN has a whole story on that, and while I can believe it to some extent, there’s a quote from a nursing home operator whose staff is 70% vaxxed, and I cannot see how this is any less urgent than getting hospital staff vaccinated. We’ve tried the carrot, now there needs to be a stick. There’s plenty of polling data to suggest that a non-trivial number of people who are vaccine hesitant will give in and get the shot if their workplace mandates it. Let’s put that to the test.

Texas gets its Medicaid 1115 waiver back

Hrmph.

It’s constitutional – deal with it

A federal district judge on Friday temporarily reinstated a 10-year extension of a federal health care program that Texas uses to help pay for health care for uninsured Texans and is worth billions of dollars annually.

The agreement was set to expire next year after federal health officials in April rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its original October 2022 expiration date.

The decision did not stop the funding for the current waiver, which provides $3.87 billion in annual funding to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

In his order on Friday, the U.S. District Judge J. Campbell Parker granted a preliminary injunction sought by Texas to block the federal government from rescinding the original Trump-era agreement. The decision removes the requirement, at least for now, for Texas to negotiate its deal with CMS if it wants 1115 funding beyond October 2022.

The decision by CMS was “likely unlawful” and resulted in “turmoil in the state’s Medicaid program,” in part because the state had already begun “reassigning staff, making plans, appropriating money, passing regulations, and engaging stakeholders to work towards implementing the necessary changes” allowed by the original deal, which was confirmed in January before it was rescinded by the Biden administration in April, Barker said in the order.

[…]

The 1115 waiver was meant to be temporary while Texas transitioned to an expanded Medicaid program under the Affordable Care Act of 2010, but that never happened because the U.S. Supreme Court ruled in 2012 that states couldn’t be forced to expand Medicaid.

Since then, the state has relied on the waiver for various programs to care for Texas’ uninsured, with Republican state leaders frequently leaning on it in their arguments against Medicaid expansion.

See here, here, and here for some background. I don’t know the technical details well enough to know if this is a reasonable decision on the merits or if Paxton once again found himself a super friendly judge. I’m not even sure if this means that the entire Trump-approved ten-year extension is back in play, or if there will be another opportunity for the Biden administration to force the issue, perhaps next year when the previous agreement was to expire. Perhaps if one of the alternate means of allowing/forcing Medicaid expansion is part of the reconciliation package, the issue can be revisited, or perhaps largely rendered moot. It does seem likely to me that Congress could change the terms of the 1115 waiver, as the issue here was over the executive action, I just don’t know who would be pushing that in the legislative process. All in all, a deeply unsatisfying state of affairs at this time.

Paxton sues over revocation of Medicaid 1115 waiver

Someone please explain to me if this has any merit.

Best mugshot ever

Texas Attorney General Ken Paxton sued the Biden administration Friday to reinstate an eight-year extension to a federal health care funding agreement, worth billions of dollars annually and set to expire next year, that the state uses to help pay for health care for uninsured Texans.

Last month, federal health officials rescinded the Trump-era extension to the 1115 waiver agreement — which Texas has had with the U.S. Centers for Medicare and Medicaid Services since 2011 and is up for review every few years — and ordered Texas to collect public input, as the agreement requires, while it renegotiates a new extension beyond its current October 2022 expiration date.

The decision did not stop the funding in the current waiver, which will continue to provide $3.87 billion in annual funding for 2021 and 2022 to partly offset free care provided by Texas hospitals to the uninsured, and to pay for innovative health care projects that serve low-income Texans, often for mental health services.

The extension, granted in the waning days of Donald Trump’s presidency, would have continued hospital reimbursements until September 2030 but allowed the innovation fund to expire.

In his lawsuit filed Friday, Paxton said the decision was a political move by President Joe Biden that was meant to force Texas to expand its Medicaid program under the Affordable Care Act of 2010.

Forcing Texas back to the drawing board on negotiations over the extension, which Paxton said would have amounted to $30 billion in federal funding through 2030, threatens to “destabilize” the programs the state funds through the waiver, he said.

[…]

The 1115 waiver was originally granted to Texas as a temporary funding bridge while the state developed its plan to expand its Medicaid program, but the U.S. Supreme Court ruled in 2012 that the ACA could not require states to do so — and Texas has since leaned on the 1115 waiver to help pay for care for the uninsured.

Supporters of Medicaid expansion have said that the state should utilize both 1115 waiver funding and expanded Medicaid eligibility, and have expressed confidence that the state would be able to negotiate the extension — with the required public input — before it expires.

“We have an attorney general and other state leaders who have made crystal clear the last few months and last few years that they have little interest in health care for working Texans — although they do have an obsession with filing lawsuits against the White House,” said Patrick Bresette, executive director of Children’s Defense Fund-Texas. “This misguided lawsuit is the cherry on top of a legislative session in which state leaders shot down all attempts to give an affordable health insurance option to janitors, cooks, grocery store clerks, and other Texans.”

“This would be a disaster for our state, and yet President Biden seems intent on thrusting his bloated model of government on everyone — including Texas,” he said in a statement Friday.

See here and here for some background, and here for a reminder that the Republicans have once again passed on the opportunity to fully expand Medicaid and make this issue moot. Let’s put aside the irony of a guy who is the lead attorney on a still-active case that would entirely kill the Affordable Care Act if he wins suing to keep federal funds flowing into Texas and ask the key question: This is a federal program, which requires federal approval. Doesn’t that mean that the federal government has some discretion here? If one accepts the premise that this move by the feds was purely capricious and driven by partisan motives, then sure, a lawsuit would be an appropriate remedy. On the other hand, if the feds reasonably believe that the extension, granted in the waning days of a President that gave little care to details and openly favored Republican states, was done in error, well, don’t they have the authority to correct that? I’m asking because I have no idea what the fine points of the law are here, and I have no reason to believe anything Ken Paxton says. That by itself doesn’t mean that the law couldn’t be on his side, though. I welcome any informed feedback on this. The Chron has more.

Today is not the day we expand Medicaid

Tomorrow isn’t looking so good either.

It’s constitutional – deal with it

The Texas House on Thursday rejected an attempt to direct the governor and state health officials to use billions in federal dollars to expand health care coverage for uninsured Texans, including working poor who earn too much to qualify for Medicaid but too little to afford their own health insurance.

On a vote of 80-68, lawmakers voted down the proposal, which was floated as a two-page amendment to the state budget on Thursday.

The debate, which was highly anticipated by advocates of expanding coverage for uninsured Texans, was expected to be heated and drawn out. It lasted less than 20 minutes.

[…]

State Rep. Garnet Coleman, a Houston Democrat who sponsored the amendment, said it wouldn’t force the state to expand traditional Medicaid but would direct Abbott and the Texas Health and Human Services Commission to negotiate a federal funding agreement, known as a 1115 demonstration waiver, to create a plan that would cover more uninsured Texans, including those who would qualify for coverage under a traditional Medicaid expansion plan.

The resulting plan could have been a traditional expansion of Medicaid to cover adults who earn up to a certain amount, or a “look-alike” that combines state and federal funds to create a state program that accomplishes a similar goal, Coleman said.

Such state-crafted plans have been passed in several states, mainly conservative states like Indiana and Ohio.

“I would like for us to expand traditional Medicaid in the optional way that the ACA says you can do it,” Coleman said on the House floor. “But we can’t do that. And we know that … That is not what this amendment does.”

Rep. Richard Peña Raymond, D-Laredo, said the idea “puts Texas in the driver’s seat, and really Gov. Abbott in the driver’s seat” instead of forcing their hand or pushing through a program unpopular with conservatives.

But Republican state Rep. Giovanni Capriglione, the only House member to speak against the bill during Thursday’s debate, said that creating a new health care program — Medicaid or otherwise — is far too complicated an endeavor to tackle in a two-page amendment and cautioned that it in fact looked like a way to expand Medicaid without a public hearing or extended floor debate.

“This topic is incredibly important, it’s complex, and frankly, it’s not appropriately handled in this amendment,” Capriglione said.

House Democrats, a handful of Republicans, and health care advocates, as well as nearly 200 groups and community leaders across Texas, still have some hope for House Bill 3871 by state Rep. Julie Johnson, D-Carrollton. That bill creates the “Live Well Texas” plan that uses a 1115 waiver to capture the federal dollars and expand Medicaid eligibility, and it includes incentives for people to continue working as well as increases in Medicaid reimbursements to attract more doctors to the program.

The bill has 76 House sponsors, nine of whom are Republicans, giving it enough support to pass the House. But it has been stuck in the GOP-led House Human Services Committee since March, waiting on a hearing that becomes increasingly less likely as the Texas Legislature barrels toward its final days at the end of May.

Only one of the Republican sponsors of HB 3871 voted for the Coleman amendment.

See here and here for the background. In a vacuum, I can accept Rep. Capriglione’s explanation for why this was the wrong vehicle to handle a complex health care topic, but given that the Lege has refused to consider Medicaid expansion for a decade, and as Rep. Coleman notes we’re only trying to do this the hard way because Republicans refuse to do it the easy way, I’m less sympathetic. Even if this amendment had been adopted, there would be no guarantee it would be in the final budget – as Scott Braddock notes, what matters is the conference committee. In theory, that means this could be revived there, but let’s just say one should not bet on that outcome. All respect to Reps. Coleman and Johnson, but we’ve seen this movie before, and I don’t expect it to end any differently this time around.

Medicaid expansion by any means necessary

Whatever it takes. But I’ll believe it when I see it, and I have a very hard time believing that the current cast of characters will do anything to make it happen.

It’s constitutional – deal with it

Texas Republicans have been swift to condemn the Biden administration for rescinding early approval of a multibillion dollar Medicaid program that would help fund emergency care for the state’s booming uninsured population through 2030.

Gov. Greg Abbott said the federal government was “deliberately betraying Texans.”

Attorney General Ken Paxton vowed to “use every legal tool available to regain the assistance Texans need.”

But the decision federal health officials announced Friday could end up being one of the biggest steps yet to extend government health coverage to low-income people in Texas since the Affordable Care Act, according to health advocates and political observers. That’s true even if it doesn’t spur immediate change.

“The Biden administration has all the cards here,” said Brandon Rottinghaus, who teaches political science at the University of Houston. “They aren’t playing nice anymore with health care expansion. They’ve got the money, so they have the leverage.”

Pressure is also coming from inside the state. On Tuesday, a group of more than 150 organizations, including chambers of commerce, trade associations and local officials signed a letter calling on lawmakers to “support increased health coverage for Texans.”

“We specifically support a coverage initiative that is bipartisan, funded through available federal dollars, structured to be neutral for the state’s budget, and designed to meet Texas’ specific needs, values and circumstances,” it said.

The letter notably did not include the Texas Hospital Association, which criticized Friday’s decision. It has supported expanded coverage in the past.

[…]

Health care advocates have been quick to downplay Friday’s announcement, saying there is still plenty of time for the state to apply again for the waiver before next year. Texas was originally approved for the extension as part of a flurry of eleventh-hour orders by Trump health officials. In doing so, it allowed the state to forgo the normal comment period.

“I think of it in terms of, Texas didn’t follow the rules, and now it’s being told to follow the rules,” said Elena Marks, president of Episcopal Health Foundation in Houston. “It’s not being told, ‘you can’t have an uncompensated care pool.’ In fact, we need an uncompensated care pool, we ought to have one. But we have to follow the rules.”

See here for the background. Rescinding the 1115 waiver extension and making Texas follow the process to re-apply for it is a shot across the bow, but a limited one. If Texas does re-apply correctly, that extension will almost certainly be granted, though perhaps for a shorter period of time or with more strings attached. The current position of the Texas Hospital Association, which is on the sharp end of the stick right now, gives Abbott et al some cover. And as the story notes, Abbott has a primary election coming up, and the very last thing he will want to do before he wins that is anything that will make it look like he capitulated to Joe Biden and the Democrats. Maybe something happens after that, but politically speaking the incentives are all wrong.

This Trib story from Wednesday afternoon appears to offer a bit of hope, but don’t be fooled into thinking it’s more than that.

Among several bills filed in the conservative Texas Legislature is a Medicaid expansion plan with bipartisan support that is similar to those adopted in some Republican-led states.

Nine House Republicans and all 67 House Democrats have publicly signed on to House Bill 3871, which would give it enough votes to pass the 150-member chamber. Although none of the proposals have gotten a hearing this session, Medicaid expansion is expected to be introduced in some form as a floor amendment Thursday when the House debates the state budget.

[…]

“The time to do this is now,” said state Rep. Julie Johnson, D-Carrollton, the author of House Bill 3871. “The deal on the table that the [federal] government offered to us is, in my opinion, irresponsible not to accept.”

Conservative lawmakers are weighing their historic opposition to Medicaid expansion against the potential of billions in federal incentives coming to Texas during a tight budget cycle.

“There is a bipartisan desire to see the cost of health care decrease. The unsustainable increase in prices, whether at the hospital, the doctor, or in health insurance premiums hits all Texans,” GOP state Rep. James Frank, chair of the House Human Services Committee, said in emailed comments to the Tribune. “But there is also concern that when Medicaid expands, that adds pressure to the private insurance market to make up the difference in reimbursements. Hence, expansion is a hidden tax on those who have private insurance, driving up the cost of care for everyone.”

[…]

Lt. Gov. Dan Patrick’s and Gov. Greg Abbott’s offices did not respond to requests for comment, but both have opposed expanding Medicaid in the past. In January, House Speaker Dade Phelan expressed doubt that Medicaid expansion would happen this session.

Among other arguments, opponents say it would crowd out current Medicaid patients who are already getting a low quality of care due to the limited number of physicians who accept Medicaid patients because of low reimbursements.

It’s nice that there are 76 votes for a bill that hasn’t gotten a hearing and would still have to get through the Senate and be signed by Greg Abbott, but it’s still vaporware for now. (Rep. Frank, the House Human Services Committee Chair, is not among the nine Republican co-authors.) The same old tired arguments against Medicaid expansion, by people who don’t like Medicaid but claim to want to “protect” it, continue to have sway. Honestly, about 95% of this story could have been written in 2019, or 2017, or 2015, or 2013. It’s a tale as old as time at this point. The urge among Republicans to stick it to Obamacare at all costs has not abated. I don’t see anything to suggest to me that something has changed in this dynamic. I will be delighted to be wrong, but until I am proven wrong I say it ain’t gonna happen until we elect enough Democrats to make it happen.

Now it really is time for Texas to expand Medicaid

Good for the Biden administration putting the pressure on.

It’s constitutional – deal with it

The Biden administration on Friday rescinded changes to a federal funding agreement, known as a 1115 waiver, that would have extended for 10 years Texas’ health care safety net for uninsured residents — teeing up a new round of negotiations before the existing waiver expires in 2022.

The Centers for Medicare and Medicaid Services said in a statement that it erred in exempting the state from the normal public notice process before granting an extension to the waiver in the waning days of the Trump administration.

The agency “has rescinded the extension approval, which corrects this oversight with as little impact as possible to the people of Texas, since the original demonstration remains intact through September 30, 2022,” it said in a statement.

The Washington Post, citing two federal health officials, said the decision was a bid to push Texas toward expanding Medicaid to cover more low-income adults, a move the state and eleven others have resisted.

The 1115 waiver reimburses hospitals for the “uncompensated care” they provide to patients without health insurance and pays for innovative health care projects that serve low-income Texans, often for mental health services. The extension — worth billions of dollars a year — would have continued hospital reimbursements until September 2030, but allowed the innovation fund to expire this year.

The earlier waiver is still in effect, and federal authorities “stand ready to work with the state” if it wishes to extend it beyond next year, according to a Friday letter from the Centers for Medicare and Medicaid Services.

The state’s rationale to get out of the normal public notice process was that health care providers needed financial stability during the coronavirus pandemic, the letter said. But the state’s request did not “meaningfully explain why the extension request addressed the COVID-19 public health emergency or any other sudden emergency threat to human lives,” it said, in part.

See here for some background, and be sure to click on the NBC News link in that post. The 1115 waivers were used during the Trump years to approve the skinniest and stingiest Medicaid expansions possible, and in typical Trump fashion were done with zero regard for existing law or protocol. The Chron has some more details.

While the state’s current 1115 waiver won’t expire until September of next year, the reversal has immediate political impacts because the state Legislature has only weeks left in its session and won’t meet again until 2023. Without certainty over how much the federal government will contribute going forward, lawmakers risk leaving huge funding gaps for counties and hospitals.

Texas Republicans, who control the state government, have long campaigned against the Affordable Care Act and have declined to expand Medicaid under the act’s provisions as they seek to overturn the law in court. The state has depended on the waiver system as a cheaper alternative that nonetheless leaves millions of Texans uncovered.

Today, Texas has the highest uninsured rate in the country, with nearly 1 in 5 people lacking coverage. That results in staggering amounts of uncompensated emergency room visits each year, some of which is reimbursed by the 1115 waivers.

[…]

Earlier this year, a group of national health associations including the American Cancer Society, the American Heart Association and the American Lung Association called out the Trump administration’s expedited approval, saying there was plenty of time to hold a public comment period before the existing waiver expires next year.

“The waiver application was hundreds of pages, I don’t think it even mentioned COVID,” said Joan Alker, a Medicaid expert at Georgetown University who had signed on to the letter. “So it was a blatant disregard of what the exemption was supposed to be for.”

The Texas Hospital Association said it was disappointed with the decision.

“This action undermines the safety net and hospitals’ ability to protect people,” president Ted Shaw said in a statement. “It puts the state’s health at serious risk and creates unprecedented levels of uncertainty for an industry that is charged with saving lives.”

Others noted that the waiver was never meant to be a permanent solution.

“The waiver was always intended to serve as a temporary bridge until the state implemented an insurance option — with federal Medicaid expansion funds — for low-wage workers whose jobs don’t provide health coverage,” said Patrick Bressette, who directs the Children’s Defense Fund Texas. “Now would be a good time to have a real conversation about Medicaid expansion.”

Texas Sen. Nathan Johnson, a Democrat from Dallas who authored an expansion bill that has some Republican support, said the state should immediately reapply for the waiver while also taking up the expansion question.

“The story being told on the Republican side is Biden’s taking away resources from vulnerable people. False,” he said. “There’s still time left under the old waiver protections to do this the right way.”

I can understand why the Texas Hospital Association is unhappy with the decision, but the root of that is the failure to expand Medicaid, which has cost Texas hospitals tons of money. The waiver lets them get a few of those dollars back, but why settle for pennies when the dollars are available? Do the expansion, like we should have done a decade ago, and everyone is better off. It may be late in this session but there will need to be at least one special session for redistricting anyway, so the legislative calendar isn’t actually a problem. The choice and the benefits are clear, and the only reason not to is sheer partisan obstinance. Quit whining and get it done already.

Medicaid and hospitals

I have three things to say about this.

A proposed change in Medicaid rules could cost Texas hospitals billions of dollars, forcing many to cut services and some rural hospitals to close their doors, health care industry officials said.

The change, aimed at increasing the transparency of how the program’s money is spent, narrows the definition of state and local funds that can be used to determine federal matching funds. That, in turn, would reduce federal funding and cost Texas hospitals an estimated $11 billion a year, industry officials said.

Houston hospitals would lose an estimated $500 million a year, said Tim Ottinger, director of governmental relations at CHI St. Luke’s Health.

A drop in funding would mean extreme hardship for many of Texas’ rural hospitals, which stand to lose some $900 million a year. The Texas Organization for Rural and Community Hospitals (TORCH) found that 46 percent of the state’s rural hospitals operate at a loss. Over the last decade, 26 rural hospitals have closed in Texas, the highest rate in the nation.

It’s unclear how many more rural hospitals could close if the proposed rule goes into effect as written, but it would be devastating to pull so much money from their budgets, said John Henderson, president of TORCH.

“A business can’t survive,” Henderson said. “But this isn’t just a business, it’s a service.”

1. I mean, you’d think that a policy that would cost the state billions of dollars and would have such a negative impact on rural areas, where access to health care is already severely lacking, would call for some kind of response from our state government. Turns out they like it, because they say it would let them cut costs. Just in the state budget, though. Counties and hospitals and the rest are on their own.

2. That said, some of those rural communities don’t seem to be too concerned about their hospitals. So maybe I shouldn’t be all that concerned on their behalf.

3. Of course, this proposed change will not survive the end of the Trump administration. None of the Democratic Presidential candidates, whatever their health care plans are, will allow this to stand. So, you know, make sure you vote for one of them this November.

State seeks Medicaid money it gave up over Planned Parenthood ban

Ugh.

Right there with them

Four years after Texas gave up millions of dollars in federal Medicaid funds so it could ban Planned Parenthood from participating in a family planning program for low-income women, the state is asking the Trump administration for the money back.

The request presents an important early test for the administration of President Trump, who recently appointed an anti-abortion official to oversee federal family planning programs. Under President Obama, federal health officials would not allow Medicaid funds to flow to the Texas program after it excluded Planned Parenthood, because federal law requires states to give Medicaid beneficiaries their choice of “any willing provider.”

If the administration agrees to restore the funding for Texas, it could effectively give states the greenlight to ban Planned Parenthood from Medicaid family planning programs with no financial consequences.

“They’re asking the federal government to do a 180 on its Medicaid program rules,” said Elizabeth Nash, a policy analyst at the Guttmacher Institute, a research center that supports abortion rights. “And depending how this shakes out, you could see a number of other states follow suit.”

[…]

In its draft waiver application, the state said it hoped that by turning Healthy Texas Women back into a Medicaid waiver program, it would improve access and participation. The application noted that Texas had the nation’s highest birthrate, with more than 400,000 births in 2015, more than half of which were paid for by Medicaid. It also noted than more than one-third of pregnancies in the state were reported as unintended, and that Texas had one of the highest teen birthrates in the country.

On Monday, at a public hearing on the plan in Austin, several women and representatives of health advocacy groups expressed concern about the request.

“A strong Healthy Texas Women program should include Planned Parenthood,” said Blanca Murillo, 25, who said she relied on Planned Parenthood for contraception that helped treat her polycystic ovary syndrome when she was a student at the University of Texas. “I’m asking the state to choose the health of Texas women — which it has a duty to protect — over scoring political points.”

Stacey Pogue, senior policy analyst at the Center for Public Policy Priorities, a liberal research group, pointed to the so-called freedom of choice provision in Medicaid and said she was concerned that “submitting the waiver as is would invite litigation.”

A spokeswoman for the Centers for Medicare and Medicaid Services, or C.M.S., which oversees Medicaid waiver programs, declined to comment.

Carrie Williams, a spokeswoman for the Texas Health and Human Services Commission, said, “We’re been encouraged to present new and innovative ideas to C.M.S. for discussion for possible funding. This is a new administration, and we’re looking at what funding opportunities may exist for us.”

Texas is also seeking to cut off all Medicaid funding to Planned Parenthood; a federal judge blocked the effort earlier this year, but the state is appealing the decision.

It’s for stuff like this that Republicans have remained loyal to Trump regardless of the disaster he creates everywhere. They want their shiny ideological objects, and it doesn’t get much shinier than shivving Planned Parenthood. Who cares if some of the money winds up going to frauds? It’s not like they actually cared about women’s health in the first place. So yes, I expect this request to be granted in short order, and then replicated in other states. The only way to undo that is going to be to undo who is in charge of the government. The Associated Press, the Trib, and the Current have more.

Let’s please get the children covered

Surely that’s not too much to ask.

It's constitutional - deal with it

It’s constitutional – deal with it

Five nonprofit organizations and community groups in Texas, including three in the Houston area, have been awarded a combined $4.78 million by the Centers for Medicare and Medicaid Services to boost efforts to enroll the state’s nearly three-quarters of a million uninsured children, the federal agency announced on Monday.

Texas leads the nation not only in the number of overall uninsured but also in the number of children under age 18 who lack health insurance coverage. More than one in 10 Texas children 18 and younger remain uninsured, according to an U.S. Census analysis and other studies.

The awards to Texas organizations are designed to get more eligible children enrolled in Medicaid and the Children’s Health Insurance Program, commonly known as CHIP.

The Texas groups receiving funds are Gateway to Care, a Houston-based collaborative assisting in access to health care; Lone Star Legal Aid, also of Houston; Children’s Defense Fund-Texas in Bellaire; the Bexar County Hospital District’s University Health System in San Antonio; and the Community Council of Greater Dallas.

Surely we can all agree that having healthy children is in everyone’s best interest. That means ensuring that all children have access to health care, including dental care, which in turn means getting all eligible children enrolled in CHIP. The return on the investment is pretty good, but beyond that, it’s just the right thing to do. This is a concrete and relatively inexpensive thing we can do for the children that we claim as a society to value. You would think that for the political party that is obsessed with “unborn” children and imaginary predators in public bathrooms, that enrolling as many eligible children as possible in CHIP would be a no-brainer. Sadly, that self-proclaimed concern form children never seems to extend that far. It’s a good thing we have the federal government and a passel of caring non-profits to step in and fill the gap.

Feds grant 15 month Medicaid waiver extension

I sure hope they keep the pressure on to expand Medicaid during this time.

It's constitutional - deal with it

It’s constitutional – deal with it

The Obama administration has agreed to temporarily keep some federal Medicaid money flowing into Texas to help hospitals treat uninsured patients, a relief to health care providers that feared losing the funds over state leaders’ refusal to provide health insurance to low-income adults.

State health officials said Monday they have struck a deal with the federal Centers for Medicare and Medicaid Services to keep the program going for another 15 months, with hospital reimbursements remaining at their current level.

Those were the exact terms the Texas Health and Human Services Commission asked for last month. Agency leaders said the negotiations were a “big win for Texas.”

“We’re pleased these innovative programs will have the opportunity to continue,” Chris Traylor, the agency’s executive commissioner, said in a statement. “These programs are improving health care for Texas’ Medicaid clients and creating cost-savings for taxpayers.”

[…]

The 15-month extension also includes an additional $3.1 billion for DSRIP initiatives.

The Obama administration had previously signaled it was likely to stop footing the bill for at least some of Texas’ uncompensated care costs. Under the Affordable Care Act, the president’s signature health law, Texas was encouraged to expand its Medicaid program to cover nearly 1 million additional adults living in poverty — a move that would have given more poor patients a means to pay for care. The state’s Republican leadership hasvehemently opposed that option, criticizing Medicaid as an inefficient government program.

Federal health officials were unswayed by that argument, repeatedly telling state leaders they had no desire to use waiver funds to pay for costs that would otherwise be covered by a Medicaid expansion.

[…]

Texas health officials say they will continue negotiating a longer term extension of the funding over the next 15 months.

Those negotiations will likely be influenced by a study of the effectiveness of the uncompensated care pool, which the federal government asked Texas to commission. The Texas Health and Human Services Commission contracted with outside firms Health Management Associates and Deloitte to submit the study by the end of August. It will address questions such as how hospitals’ uncompensated care costs would be reduced under a Medicaid expansion.

If Texas and the federal Centers for Medicare and Medicaid Services do not reach an agreement at the end of the 15-month extension, in December 2017, the Obama administration said it “expects” that uncompensated care funding would be reduced after that.

“Specifically, the reduction will limit the size of the Uncompensated Care pool to the costs of uncompensated and charity care for low-income individuals who are uninsured and cannot be covered” under a Medicaid expansion, wrote Vikki Wachino, a senior federal health official, in a letter to the Texas Health and Human Services Commission.

Additionally, the DSRIP pool would be reduced by 25 percent in 2018 and by an additional 25 percentage points each year after that, according to federal officials.

See here, here, and here for some background, and here for a copy of the letter CMS sent to Texas. I don’t really have anything to say that I haven’t said before. Texas needs to expand Medicaid, and if the state continues to refuse to do so, the federal government should not take any steps to mitigate the consequences of that decision. It’s up to the next Legislature now. State Rep. Garnet Coleman, Trail Blazers, and the Austin Chronicle have more.

Two Medicaid stories

From the Trib:

It's constitutional - deal with it

It’s constitutional – deal with it

State health officials confirmed Tuesday they have asked the Obama administration to keep a 15-month lifeline of federal Medicaid money flowing into Texas to help hospitals treat uninsured patients.

That money would offer temporary relief to health care providers who face losing the funds — some $3.1 billion annually — over state leaders’ refusal to provide government-subsidized health coverage to low-income adults under the Affordable Care Act, President Obama’s signature health law.

Federal officials previously signaled they would stop footing the bill for at least some of Texas’ costs for “uncompensated care” — the burden on hospitals when patients can’t pay for their visits. Under the Affordable Care Act, Texas was encouraged to expand its Medicaid program to cover nearly 1 million additional adults living in poverty — a move that would have given more poor patients a means to pay for care. The state’s Republican leadership has vehemently opposed that option, criticizing Medicaid as an inefficient government program.

[…]

First created as a $29 billion pot of money paid to Texas health care providers over five years, about 40 percent of that money came from local funds — mostly property tax dollars — and 60 percent from the federal government. The Obama administration approved the program in 2011, and it was set to expire in September.

By asking for the program to be renewed for a significantly shorter timeframe, state health officials indicated that they expect the federal government will be reluctant to continue handing out cash to reimburse hospitals for patients who can’t pay for their visits. Federal health officials have repeatedly told state leaders they have no desire to use waiver funds to pay for costs that would otherwise be covered by a Medicaid expansion.

In Florida, the Obama administration recently agreed to extend a similar source of hospital funding in that state, but only for two years and at a significantly reduced rate. That arrangement diminished the state’s low-income pool by about 50 percent for the first year and 70 percent for the second.

See here and here for some background, and here for a copy of the letter. This is the 1115 waiver, and I’ve been rooting for the feds to tell Texas to go pound sand unless they expand Medicaid. This is at least a step in that direction.

And from Think Progress:

The Obama Administration just sent a strong signal to states trying to defund Planned Parenthood, warning all 50 states that attempts to strip Medicaid funding from the women’s health care provider is most likely illegal.

The letter, sent to each state’s Medicaid director, cautions lawmakers that “providing the full range of women’s health services… shall not be grounds for a state’s action against a provider in the Medicaid program.” In other words, the fact Planned Parenthood provides abortion services in addition to other women’s health services is not legal grounds to cut it off from Medicaid funding. It stipulates that the only justifiable reason to remove a provider’s Medicaid funding is if that provider isn’t able to bill for or perform covered medical services.

“Once again, the Centers for Medicare and Medicaid Services has made it clear that it’s illegal for politicians to tell women where they can and cannot go for care,” said Cecile Richards, President of Planned Parenthood, in a statement.

[…]

The Obama Administration has warned specific states before that cutting off Medicaid funding for Planned Parenthood may violate federal law, but this is the first time that they have sent a letter to every state in the country.

As we know, Planned Parenthood has filed a lawsuit against Texas after it announced it was cutting PP out of any program it hadn’t already cut them out of as punishment for those faked videos by the fraudsters Daleiden and Merritt. I don’t know what effect, if any, this federal action will have on that, but I do know we could easily solve all these problems (and more) if Texas would expand Medicaid and obey the law. It’s all so simple, really.

Texas vs Planned Parenthood, part one million

This was going to happen sooner or later.

Right there with them

Right there with them

Texas health officials say they are kicking Planned Parenthood out of the state Medicaid program entirely over what they called “acts of misconduct” revealed in undercover videos filmed earlier this year.

Republican state leaders, who vehemently oppose abortion, have worked for years to curb taxpayer funding of Planned Parenthood — despite the fact that its clinics may not receive such funding if they perform the procedure.

Monday’s decision means even Planned Parenthood clinics that only provide well-woman care, like cancer screenings, pregnancy tests and birth control, will also be cut out of receiving dollars from Medicaid, the joint state-federal insurer of the poor.

The vast majority of Medicaid funding for Planned Parenthood clinics in Texas comes from the federal government. Texas spent just $310,000 from its own coffers on the women’s health organization in 2015, but it also dispersed $2.8 million in federal dollars to those clinics. A spokesman for the federal Centers for Medicare and Medicaid Services did not immediately respond to a request for comment.

[…]

On Monday, the Texas Health and Human Services Commission’s inspector general, Stuart Bowen, wrote to Planned Parenthood Gulf Coast that the women’s health provider had violated state Medicaid rules and put Texans at risk of infection. Citing the sting videos, Bowen said Planned Parenthood officials disregarded federal law by agreeing to change the timing or method of abortions in order to procure fetal tissue for medical research.

As a result, the state will no longer allow any Planned Parenthood clinics in Texas to receive Medicaid funding. Last year, Planned Parenthood clinics in Texas received $3.05 million in federal funds through Medicaid for family planning services like birth control and pregnancy tests.

Planned Parenthood Gulf Coast spokeswoman Rochelle Tafolla described the state’s efforts to block Medicaid patients from receiving care from any of the organization’s clinics as “politically motivated.” Planned Parenthood Gulf Coast does not currently participate in fetal tissue donation, the organization says, but did in 2010, in conjunction with a University of Texas Medical Branch study on miscarriage.

“Tens of thousands of women are already going without care after years of policies aimed at blocking access to care at Planned Parenthood,” Tafolla said. “Now Texas politicians are using a thoroughly discredited, bogus attack against Planned Parenthood as a shameful excuse to attack Texas women’s health yet again.”

This has been the end goal for Texas Republicans for several years now, so like I said, no surprise, and one excuse is as good as another. I would point out that multiple states have investigated these videos and found nothing – Texas, as well as Harris County, is doing its own investigation, and one presumes they have nothing worthwhile to show for it as yet. As such, this may be their consolation prize, since coming away empty-handed was not an option. What comes next is almost certainly a lawsuit, since Texas doesn’t exactly have the authority to do this. If they could have, they would have done this much earlier than this. In the meantime, still more women will lose their access to healthcare. That’s the reality we unfortunately live in, and much as I hate to say it, nothing will change until our state leadership does. BOR, Newsdesk, and the Observer have more.

No, seriously, expand Medicaid or else

Bring. It. On.

It's constitutional - deal with it

It’s constitutional – deal with it

The federal government is officially holding state leaders’ feet to the fire, hoping to get Texas to expand its Medicaid program to provide health insurance to more low-income Texans.

Federal officials called the state’s health agency this week to say that Texas’ reluctance to expand Medicaid — a key tenet of President Obama’s signature health law — will play into whether his administration extends a waiver that helps the state’s hospitals cover uninsured patients.

The development follows news from Florida, where a similar tug-of-war is playing out between the federal government and a Republican-controlled statehouse that opposes Obamacare but hopes to renew billions of dollars in hospital funding. This week, federal officials sent a letter to Florida lawmakers that said Medicaid expansion “would reduce uncompensated care in the state,” making it “an important consideration in our approach regarding extending” the state’s hospital waiver.

Linda Edwards Gockel, a spokeswoman with the Texas Health and Human Services Commission, confirmed Friday that federal health officials called the Texas agency Thursday afternoon to relay a similar message.

Officials from the federal Centers for Medicare and Medicaid Services “said they recognize each state is different, but they intend to use the same three principles outlined in their letter to Florida as they evaluate uncompensated care funding pools in all states,” Edwards Gockel said in an email. “We don’t have more details than that at this point.”

Tom Banning, chief executive of the Texas Academy of Family Physicians and an advocate for Medicaid expansion, said in an email that the call “should be a wake up.” Annually, Texas hospitals receive billions of dollars combined by way of the federal “transformation waiver.” Losing that money “will have a crippling effect throughout Texas,” Banning added.

The Texas hospitals waiver runs through September 2016, but the 2015 legislative session is the last chance for state lawmakers to negotiate a renewal before then. The current session is slated to wrap up on June 1, barring a governor-called special session.

Estimates for the value of that waiver vary. The Texas Hospital Association, which supports some form of Medicaid coverage expansion under the Affordable Care Act, estimates the waiver’s five-year value at $29 billion.

See here for the background. As noted in the story, the feds are similarly putting the screws to Florida. There’s basically zero chance that anything will get passed this session – Sen. Rodney Ellis tried to get a Medicaid expansion amendment through during the budget debate and failed, while Greg Abbott is holding firm and whining about how mean the feds are being to him – so it’s just a matter of whether the feds follow through in 2016 and if enough pressure can be brought to change things in 2017. Anyone want to place a bet on that? The only semi-retired Burka has more.

Texas Obamacare enrollments top 850K

And counting.

It's constitutional - deal with it

It’s constitutional – deal with it

Officials at the Department of Health and Human Services Wednesday announced nearly 860,000 Texans so far have enrolled in health insurance marketplace coverage with a month left still left to go until the 2015 open enrollment period ends.

It’s unclear how many of those signups are new marketplace customers. Last year, nearly 734,000 Texans, many of whom had never been insured, signed up for coverage. About 198,000 of them were in the Houston area.

“As of Jan. 9, 859,377 Texans have access to quality, affordable health coverage for 2015 through the Health Insurance Marketplace,” said Health and Human Services Secretary Sylvia Burwell in a written statement.

Good to hear. National enrollments have been strong as well. It seems eminently reasonable to me that Texas could top one million signups by February 15, given the likelihood (as was the case last year) of some number of people waiting till the last minute to get it done.

There’s also an intensified focus on the Latino community.

Officials plan more than 600 enrollment events nationwide, including a few in the Houston area, that target Hispanics in an effort to get more signed up for coverage under the Affordable Care Act. In the meantime, grass-roots organizations and the Department of Health and Human Services are spreading the word about the marketplace by using webinars, Twitter, advertising and Spanish television telethons.

“We’re doubling down,” Health and Human Services Secretary Sylvia Burwell told reporters Wednesday, noting that the agency has dedicated a third of its advertising budget to Spanish speakers. “The Latino community is one of the fastest growing communities in the country. We’re specifically focused on this community because of the health disparities that exist for them and we think having insurance will help.”

[…]

Researchers have found Texas Latinos were more than twice as likely as Anglos to enroll in marketplace coverage. They also discovered Hispanic adults in Texas have more difficulty affording health care and are three times as likely to be uninsured.

Burwell repeatedly has said Spanish speakers would be targeted for more outreach this enrollment period. Insurers and enrollment organization trained more application assisters to accommodate Latino applicants and marketplace officials simplified the insurance application process, expanded the number of documents people could use to verify their identities and income and made it easier for applicants to use hyphenated names, which are common in Latino communities.

“We’re working to meet Latino consumers where they are, whether that’s online, over the phone or in person,” Burwell said.

There’s a lot of potential there, and one thing we learned from the first round of enrollments was precisely that these customers needed more engagement to get signed up. I hope this has the desired effect, and that we can learn more for the next time.

What would happen to all these people if SCOTUS takes the opportunity to gut subsidies for the national exchange? My guess is that as are the million or so folks that would qualify for Medicaid under a normal expansion plan, they’d be SOL. Oh, I’m sure that Rep. John Zerwas will put forth a bill to create a Texas state exchange, as he has done before. He’ll have the support of all the Dems, a few honorable Republicans, every non-crazy local official, and the business establishment, but it won’t be enough. Nothing will change till we start to win more elections. I wish I had a sunnier outlook than that, but I don’t. Sorry.

Does any of this sound like “Medicaid Expansion” to you?

So Wonkblog, TPM, and BOR, all riffing off the same news story in which Greg Abbott had a clandestine meeting with Houston-area legislators and may have said some things that made them think he might be open to “Medicaid expansion”, are all talking about it as though it’s a thing that could happen. Here’s Wonkblog, which had the most detailed report:

It's constitutional - deal with it

It’s constitutional – deal with it

If Abbott did back Medicaid expansion funding, worth about an estimated $100 billion to the state over 10 years, it would be arguably the biggest “get” for the Obama administration since the Supreme Court made the expansion voluntary more than two years ago.

As Texas attorney general, Abbott joined the lawsuit against Obamacare that reached the Supreme Court in 2012. His predecessor, Gov. Rick Perry, has been one of the most outspoken opponents of the Medicaid expansion, and Abbott campaigned against the Medicaid expansion leading up to the November election.

According to the Texas Tribune report, he’s interested in the expansion deal Utah Gov. Gary Herbert struck with the Obama administration after months of negotiations. Herbert’s plan would use Medicaid expansion dollars to buy private coverage for low-income adults earning below 138 percent the federal poverty level, or about $16,100 for an individual, with some cost-sharing requirements.

Of the 23 states that haven’t expanded Medicaid, Texas by far has the most low-income adults living in the “coverage gap” – people who earn too much to currently qualify for Medicaid but don’t earn enough to receive subsidies to purchase health insurance through Affordable Care Act exchanges. About 948,000 adult Texans fall into this category, or about 25 percent of all Americans in the coverage gap, according to the Kaiser Family Foundation.

It’s still not clear whether Abbott’s thinking on Medicaid has changed. He’s recently called for a block grant of current Medicaid funding, which would be a lump sum to run the health-care program with far less oversight from the federal government — an idea that doesn’t sit well with Democrats. And Abbott has said Texas couldn’t afford the expansion when the federal funding match drops to 90 percent of the program’s cost in a few years.

The expansion issue is far from dead in Texas. A legislative health committee earlier this month rejected the traditional expansion but left the door option for future waiver negotiations with the federal government. A separate federal Medicaid waiver, worth close to $30 billion, could provide a major leverage point for the Obama administration when the waiver expires in 2016.

I’ve linked to it before, but here’s that Senate interim committee report, which covered other topics including Medicaid. The sum total of what they wrote about Medicaid is only nine pages, beginning on page 22, so you can read it all yourself if you want, but I’ll save you some time and reprint the recommendations here:

1. Texas should encourage congressional action to operate Medicaid as a block grant program and should simultaneously continue to pursue a waiver from the Centers for Medicare and Medicaid Services (CMS) to allow the state increased flexibility in the operation of our Medicaid program. While the delivery of Medicaid funds through a block grant is ultimately a decision of the U.S. Congress, the state should actively urge such action at the national level. Additionally, HHSC should continue to seek a waiver from CMS that will allow Texas to contain costs and increase personal responsibility by enacting cost sharing requirements, tailoring benefits to more closely align with individual needs, enhancing efforts to prevent fraud, waste, and abuse, and eliminating unnecessary administrative costs.

2. Support successful programs and entities that have local buy-in and include local funding sources.

  • Successful programs that serve the uninsured and are funded through state and local sources, such as mental health services offered through Local mental Health Authorities (LMHAs) and county indigent programs, should be supported and potentially expanded by the Legislature.
  • Programs that enable low-income families to access private market health coverage such as the Health Insurance Premium Payment (HIPP) program should be promoted and expanded. This program reimburses families of Medicaid-eligible clients for their share or a portion of their share of an employer-sponsored health insurance premium, only in cases when the state has determined that paying the premium is more cost-effective than enrolling the Medicaid-eligible family member in the Medicaid program. In Fiscal Year 2013, there were 7,194 active HIPP cases serving 9,657 Medicaid-eligible individuals and 26,409 total clients. Expansion of the HIPP program should be considered as a way to connect family members of Medicaid-eligible individuals to affordable private health insurance.
  • Texas should support settings that serve high numbers of uninsured Texans, such as Federally Qualified Health Centers (FQHCs). FQHCs provide a medical home for many Texans without health insurance. FQHCs are facing a “fiscal cliff” in 2016, when the federally-funded FQHC Trust Fund is expected to be discontinued. Texas should advocate for continued funding for the Trust Fund and supply state funds, as available, to support this vital part of our safety net.

So I ask again, does any of that sound like “Medicaid expansion” to you? Some of these may be good ideas – I’m not enough of a wonk to say – but it’s not clear to me how expansionary any of them are, or what any of them have to do with “Medicaid”. I get that there’s an aversion to using the term “Medicaid” in any policy description, but either the goal is to provide health insurance to most if not all of the people who would be eligible for Medicaid under an ACA-style expansion or it’s not. I don’t see anything that points in that direction, and until I hear Greg Abbott use words that signal an intent to, you know, EXPAND health insurance coverage in some form, then I say deep skepticism is the rational response.

Now, I do appreciate some journalistic attention to this, however thin the reed is that we’re all hanging on, so let me suggest a couple of questions that could be asked the next time Abbott deigns to talk to the press about this, or anything else.

1. Is your primary goal still to seek block grants for Medicaid? How will that meet the goal of covering more Texans?

2. What prompted your change in thinking on this?

3. How will you overcome the opposition of your Lieutenant Governor, many of the Republicans in the Legislature, and your ideological allies Such as the TPPF?

Those last two questions are on the assumption that Abbott is indeed interested in pursuing something other than block grants. Which, to be clear, I still think is what he intends to do. As such, those questions are likely moot, but let’s keep them in our back pockets just in case. I don’t expect to need them, but what the heck. In the meantime, as I’ve said before, let’s keep our eye on the ball.

Obamacare 2.0

The open enrollment period for the Obamacare insurance exchanges is going on right now. This year, the feds are taking a more direct approach to getting people to enroll.

It's constitutional - deal with it

It’s constitutional – deal with it

Secretary for Health and Human Services Sylvia Burwell, whose appearance at Monday’s news conference [in San Antonio] is part of a national tour to talk up marketplace successes, reported that of those who signed up during the first enrollment period this year, 7 out of 10 had premiums under $100. Nationwide, 65% of applicants qualified for subsidies, she said. In Texas, 84% of Texans got financial help, according to the Center for Public Policy Priorities in Austin.

“We as a people have a moral obligation to see that everybody has access to quality and affordable health insurance,” said Mayor Ivy Taylor who joined Burwell at the news conference. “A community prospers when its citizens are healthy.”

Burwell urged people without insurance to visit HealthCare.gov, choose the best plan among many options, and sign up by Dec. 15 to have coverage starting Jan. 1. Enrollment for 2015 will remain open until Feb. 15.

To those who signed up last time, Burwell emphasized that even if they are happy with the plan they already have, they need to re-enroll. About 90% of the information entered last time will appear on the form so people don’t have to re-enter it. Burwell said it’s important to make sure the information remains accurate and that the plan individuals previously chose is still the best one to meet their needs; 25% more plans were added this time.

The Health Insurance Marketplace enrolled 734,000 Texans in 2014. Bexar County accounted for 77,000 of those newly insured, a number that far exceeded the goal of 46,000, which remains the goal for the current enrollment period. Bexar County Judge Nelson Wolff, in attendance on Monday, has helped lead this effort, but in Bexar County, 27% of the population remains uninsured. Of those, 75% identify themselves as Hispanic, according to Andrea Guajardo, speaking for Enroll SA, a coalition of 40 organizations and 176 trained volunteers in Bexar County trained to help people sign up for insurance.

Asked about HHS’s outreach to Hispanic uninsured residents, Burwell pointed to several initiatives.

  • Spanish language call service. “In the early days of enrollment, out of 200,000 calls to our call center, 20,000 were using our Spanish-speaking call service.”Burwell said.
  • Spanish language equivalent of HealthCare.gov: CuidadodeSalud.gov.
  • Increased the number of Spanish speakers providing in-person assistance to help with online sign-up.
  • Improved interface for mobile users. “The Latino population has a deeper penetration of mobile use than the population as a whole.”

“One of the things we learned from the initial enrollment was the importance of trusted voices,” Burwell said. “I’ve had a chance today to talk with the leadership of the community and the stakeholders about their work and to hear their feedback, so we can make things better.”

Secretary Burwell was in Houston the week before that.

With some 6 million Texans still uninsured, Burwell’s early appearance this go-round shows a renewed fight to increase the health care law’s impact in Texas, where the governor’s office has refused to create a state-run marketplace or accept billions of dollars in federal funding to expand Medicaid to extend coverage to millions more people.

State and local organizers say the first insurance sign-up period helped them become more organized and strategic as they prepared for the 2015 open enrollment period.

They intend to hold multiple enrollment events, provide additional one-on-one application assistance opportunities and include more grass roots organizations and community leaders in educating the uninsured about marketplace coverage. They have data showing where the uninsured live. The key is deploying the appropriate organizations and people to reach target areas and groups, including Hispanics and young people.

“We learned about the importance of follow-up and the need for a lot of outreach,” said Mimi Garcia, the Texas state director for Enroll America, a national insurance advocacy organization. “There’s a lot of work to do in Houston. That’s going to be a big focus area.”

Organizers learned from last year’s open enrollment that the more conversations they have with uninsured residents, the more likely they are to convince someone to buy health coverage, Garcia said by telephone from a conference in New Orleans. She said the goal is for people to view purchasing health insurance as routine a practice as paying taxes or auto insurance.

[…]

The state’s uninsured rate dropped about 2 percent this year, but Elena Marks, president and CEO of Houston’s Episcopal Health Foundation, a philanthropy that will fund health care providers, said many Texans gained employer-based insurance as the economy created more jobs.

In comparison, California’s uninsured rate dropped nearly in half, from 22 percent to a little less than 12 percent, in large part to the state’s decision to expand Medicaid coverage to cover more of its low-income, working residents.

Marks said it makes sense for Burwell and other officials to bypass Texas’ political leadership and instead work with local governments, agencies and organizations, including those in the Houston area, to find the uninsured and enroll them in health coverage.

“Having her show up brings attention to the issue,” said Marks, who also is a non-resident health care fellow at Rice University’s Baker Institute.

Marks, who did not attend Burwell’s news conference, said new carriers are making the Texas marketplace more competitive this year.

Risha Jones, deputy director of Houston’s Department of Health and Human Services, said her agency’s goal is to directly contact 100,000 uninsured residents and reach another 400,000 through community and educational outreach. She said federal officials recognize the Houston area needs assistance in reaching its uninsured residents and has pledged to help. They haven’t yet set an enrollment goal.

“They are making us a priority,” Jones said, who introduced Burwell at the news conference. “We’re on the radar.”

It was a nice surprise seeing my friend David Ortez in the story, as an example of someone who was able to get health insurance through the Affordable Care Act and the exchanges. Ortez is a recent law school graduate and one of many people under the age of 30 who stands to benefit from the ACA. There’s a separate effort to get those folks, known as the Young Invincibles, to enroll. Unlike last year with the healthcare.gov meltdown, the first week of the enrollment period saw half a million people sign up, with about that many fill out applications. About half of those enrollees are first-timers. It would be awesome if this year Texas could top the one million mark for coverage. Imagine what it could be if anyone in state leadership had any interest in helping make this happen. Daily Kos has more.

Expand Medicaid or else

Turns out the federal government has more leverage over Texas than you might think.

It's constitutional - deal with it

It’s constitutional – deal with it

If Texas wants to keep receiving billions of federal dollars to help hospitals care for uninsured patients, state lawmakers may have to look again at expanding Medicaid coverage for impoverished adults, some political observers say.

That’s because in 2016, Texas will have to ask the federal Centers for Medicare and Medicaid Services to renew a five-year waiver to pump $29 billion into state health care coffers.

Since landing its first such waiver in 2011, Texas leaders have defiantly refused to expand Medicaid as envisioned under the Affordable Care Act, leaving more than 1 million impoverished Texans with no health insurance.

With the waiver renewal nigh, observers said, there’s some expectation that the federal agency will hold the waiver approval hostage in exchange for Medicaid expansion.

“CMS is going to hold that over Texas’ head to say, ‘You want this money? You do the expansion,’” said Matt Salo, executive director of the National Association of Medicaid Directors. “It’s one of the points of leverage that CMS now has.”

Texas received the 2011 Medicaid waiver in part to reimburse hospitals for care provided to patients who couldn’t pay. Two years later, state leaders under Gov. Rick Perry declined to expand Medicaid, criticizing the program as inefficient.

That left a “coverage gap” of more than 1 million Texans too poor to receive federal subsidies for private health insurance but too rich to qualify for coverage under Texas’ current, restrictive Medicaid requirements.

Now, policy analysts on the left and right say, the feds are likely to be less sympathetic to Texas’ request for another waiver to help pay for uncompensated care.

A similar tug-of-war is playing out in Florida, said Joan Alker, executive director at the Center for Children and Families at Georgetown University. In May, the federal government renewed Florida’s waiver to reimburse hospitals for just one year, rather than the standard three, “which was very unusual,” Alker said.

[…]

State Rep. John Zerwas, R-Richmond, one of the lawmakers who advocated for the “Texas solution,” said the Legislature would revisit coverage expansion during the session.

“It still behooves us as a Legislature to figure out, what’s the policy going to be around these people?” he said. “I’ll be the first to say that finding a solution for these million and a half people is important.”

And the transformational waiver from 2011 is already a source of some conflict with the federal government. CMS is currently withholding $75 million in waiver money that Texas used to reimburse private hospitals while federal officials review whether any rules were broken.

Tiffany Hogue, policy director for the Texas Organizing Project, which has worked to get Texans to sign up for health coverage on the exchange, said Medicaid expansion would be a top priority for her group during the legislative session.

“It’s absolutely going to be a battle cry for us,” she said. “The sheer number of uninsured — that’s daunting.”

Still, Alker said she was skeptical that Texas would expand Medicaid anytime soon.

“I remind myself when the Children’s Health Insurance Program was passed in 1997, Texas was the last state in the country to pick up the program,” she said. “That may be instructive moving forward.”

It’s always a safe bet to assume that the Legislature will fail to do the right thing when given the chance. I for one will be rooting for the feds to apply the screws as hard as they can in pursuit of a Medicaid expansion deal that would do untold amounts of good for more than a million people, not to mention be a nice bit of stimulus for the Texas economy. Making Ted Cruz’s head explode would be the cherry on top. Against that, when the Republicans from Greg Abbott on down (with the honorable exceptions of Zerwas et al) dig their heels in, perhaps this will finally be the impetus to get the Texas Medical Association to quit trying to placate the bullies and start working to actually further their own and their patients’ best interests.

And the first open enrollment period comes to an end

Lots of people signed up in the last few days of enrollment. Some tried but came away empty.

It's constitutional - deal with it

It’s constitutional – deal with it

Some of the hundreds of Houstonians who sought last-minute help enrolling for the Affordable Care Act on Sunday left thrilled to have health insurance for the first time in their lives, while others walked away frustrated by high prices, long waits and computer glitches.

“The lowest price plan for me was $387 per month and included a $6,000 deductible. Is this what they think people can afford who are unemployed? This is outrageous,” said Lupe Escalante, 63, a recently laid-off office administrator who attended an enrollment event Sunday at Community of Faith church in north Houston, one of a bevy of events held to help people meet the Monday deadline.

Under the law, uninsured people will be subject to fines of $95 per adult and $47.50 per child – a $285 family maximum – on next year’s income taxes. However, individuals who earn less than $10,150 and married couples earning less than $20,300 will be exempt from the penalty.

Extensions can also be granted for people who started, but did not finish enrollment, by the deadline.

For reasons unclear, the story fails to explain why Ms. Escalante did not get a quote for a policy she could afford. The simple answer is that she almost certainly falls into the coverage gap, earning too much money to qualify for Medicaid but not enough to receive a subsidy. The reason for the existence of the gap is that Texas was one of many states to not expand Medicaid, for which Ms. Escalante would surely now qualify if Rick Perry and the Legislature had done so. Alec MacGillis spells it out.

In Texas, parents can only qualify for Medicaid if they earn less than 19 percent of the poverty level—that is, below $4,531. In Alabama, it’s even lower—16 percent of the poverty level. It’s barely higher than that in Louisiana, Georgia, Missouri, and Mississippi and Florida, all of which have their eligibbility threshold set below 40 percent of the poverty level—that is, below $9,540 for a family of four. In other words, one must be subsistence-level indigent in these states to even think about qualifying. And that’s only if one has kids—if one is a non-disabled adult without dependent children, forget it: no matter how poor you are, you don’t qualify for Medicaid.

So: right now, we have passed a law meant to expand coverage to all Americans, and yet it does not reach the poorest of our fellow citizens in nearly half the states in the country. That, on its face, is a major policy failure. No one really wanted to say this during the law’s drafting, but its underlying goal was to get coverage to people in red states where there was no local political will to address the problem. It’s generally preferable to let states address their own needs, but in this realm, only Massachusetts and a few others had even attempted to bring about near-universal coverage. The only way people in Birmingham or Brownsville were going to get covered was if the federal government saw to it that they did.

We know how that worked out. Despite all the obstacles here and in other states, many people tried to enroll over the weekend and on Monday, pushing the total signup number up towards 7 million, the number that had been originally floated around before the healthcare.gov site took the month of October off. Even more people than that now have insurance because of Obamacare, and there may be many more that are not being counted by current metrics. We’ll know what the final Texas number is soon, but we won’t really know what the national numbers are for months. Whatever they wind up being, the reality is that they could and should have been a lot more. All we needed was state leaders who cared about solving a problem more than they cared about making fools of themselves on Facebook. You wouldn’t think that would be so hard to do. Wonkblog and Jonathan Bernstein have more.

ACA enrollments top 200K in Texas

Despite continued fierce resistance from state leadership, people keep signing up for health insurance in Texas via the Healthcare.Gov exchange.

It's constitutional - deal with it

It’s constitutional – deal with it

Enrollment in the federal health insurance marketplace continued to steadily climb in January, according to data the U.S. Department of Health and Human Services released Wednesday. In January, another 89,500 Texans selected a health plan on the insurance marketplace created by the Affordable Care Act, the department reported.

“Today’s enrollment figures are more proof that Texans are ready and willing to push past the barriers that Gov. Perry has put in the way of the new Health Care law,” Ginny Goldman, executive director of the Texas Organizing Project, which is assisting enrollment efforts across the state, said in a statement.

As of Feb. 1, the total number of Texans who have enrolled in a health plan jumped to 207,500 from 118,000 at the end of 2013. Across the nation, enrollment grew to 3.3 million, a 53 percent increase over enrollment in the previous three months.

“These encouraging trends show that more Americans are enrolling every day, and finding quality, affordable coverage in the Marketplace,” U.S. Health and Human Services Secretary Kathleen Sebelius said in a statement.

[…]

Texas has been a priority state for enrollment efforts, said Julie Bataille, communications director for the Centers of Medicaid and Medicare Services, and they’re working closely with local organizations and government officials to assist enrollment efforts.

“A lot of the activities that we’re doing in Texas in particular, understandably, are focused on reaching citizens who speak both English and Spanish,” she said.

John Davidson, a health policy analyst at the conservative Texas Public Policy Foundation, said enrollment was strikingly low, given the total number of uninsured Texans.

“In a state with more than 6 million uninsured, you would expect more than 207,546 people would have bothered to sign up after four months of open enrollment,” he said in an email. “This suggests that many Texans do not think the exchanges plans are all that good of a deal after all.”

But Phillip Martin, deputy director of the left-leaning Progress Texas, said that it took Texas four years, from 2006 to 2010, to achieve a similar spike in enrollment on its own — 232,000 children — in the Children’s Health Insurance Plan.

“In the past, it took years to see the kind of health coverage expansion in Texas we’ve seen in the last few months thanks to the Affordable Care Act,” he said in an email.

Davidson’s criticism is kind of hilarious. Why aren’t there more of those benighted suckers signing up for this horrible, fascistic failure of a system that’s totally going to doom us all to a fate worse than not having health insurance in the first place? Don’t you people listen to me when I tell you what’s good for you? Never mind all of the barriers that Rick Perry, David Dewhurst, Greg Abbott, and all the legislators that listen to people like Davidson put in place to keep millions of people off of health insurance. All these people that we’re prevented from getting health insurance still don’t have health insurance – see, it’s a failure, just like I said it would be!

Anyway. Davidson’s BS aside, the pace of enrollments in Texas mirrored the national trend, which showed stronger numbers in January than originally projected. Part of that is catchup from the first two months, but it’s still positive, and portends the likelihood that final signup numbers will be pretty close to what was expected in the beginning. Texas ought to exceed half a million, which is less than ten percent of our shameful total number of uninsured people, but will still be a half million more than Perry and his crew ever helped. And the push continues:

On Saturday, February 15, several community organizations will come together to host a bilingual community event to help Latinos learn about and enroll in new health care plans available under the Affordable Care Act (ACA) . Attendees will learn about new insurance plans, discover what financial help may be available to them, and work with trained experts one-on-one to enroll on site.

The event, celebrating Heart Health, will be hosted by Dia de la Mujer Latina, a national nonprofit organization focusing on Latino health since 1997. Planned Parenthood Gulf Coast and Get Covered America will be providing an opportunity for many underserved populations to learn about insurance options and enroll. Certified ACA navigators will be on hand to provide in person assistance. On the day of the event, attendees interested in enrolling will need to provide an email address, social security number, proof of legal residency (residence card or citizenship certificate), and income verification in order to apply.

Most eligible, uninsured Latinos don’t know how the health care law will affect them. Fifty-three percent of Latinos in Harris County had no health insurance coverage at the time of the 2010 American Community Survey; and in the state of Texas, there are 5.7 million Latinos without insurance. This information session will better inform people in the community about their benefits under the Affordable Care Act.

That’s from a media advisory I got about an event occurring tomorrow at the Hiram Clarke Multi Service Center, 3810 West Fuqua, from 11 to 3. There are a lot of groups out there doing this hard work, all over Texas. Imagine what kind of results they could be getting if people like John Davidson would just get out of their way. Wonkblog and BOR have more.

Arkansas will expand Medicaid

If they can do it

It's constitutional - deal with it

It’s constitutional – deal with it

[Friday], the Center for Medicaid and Medicare Services notified state officials in Arkansas that it has approved the states’ Medicaid expansion plan. And this is not any old expansion plan: Arkansas will be the only state in the country that will use Medicaid dollars to purchase private health insurance for its new public program enrollees.

“CMS is pleased to approve Arkansas’s Medicaid 1115 Waiver application,” Medicare spokeswoman Emma Sandoe said in a statement. “Arkansas and CMS worked together to find flexibilities that gave the state the tools to build a program that worked for them and their residents. We appreciate the collaboration with Arkansas throughout the process and applaud their commitment to providing Arkansans with access to high-quality health coverage.”

There are about 200,000 Arkansans who qualify for the Medicaid expansion. Instead of having them enroll in the public program, like other states will do, Arkansas will send them to their new health insurance marketplace to buy individual plans. When they get to the point of purchase, the Medicaid agency will foot the tab for their health insurance coverage.

The Arkansas expansion will start open enrollment just five days from now, on Oct. 1, alongside the 25 other states planning to expand the program. Benefits will begin Jan. 1.

The idea of using Medicaid expansion funds to pay for private insurance for those that would have qualified for Medicaid under Affordable Care Act expansion guidelines was proposed earlier this year, while the Lege was in its first session. House Speaker Joe Straus seemed open to this kind of idea, but he had precious little company on his side of the aisle. The quasi-Medicaid “expansion” bill that made it out of the House before withering on the vine insisted on asking for a block grant first, as that is Rick Perry’s obsession, but maybe – MAYBE – once that door is slammed shut again there will be some willingness to look at this plan again, however imperfect it is.

An awful lot of people tried to sign up for insurance exchanges on Tuesday

That’s a very good thing, even if technical difficulties prevented many of them from completing the job.

It's constitutional - deal with it

It’s constitutional – deal with it

On the first day of sign-ups for President Barack Obama’s health care reform, a wave of consumers across the nation, including many Texans, sought Tuesday to enroll in online health care marketplaces, but glitches with the federal website prevented them from obtaining information about coverage plans and rates.

“I wanted to get in and see what my options are to get signed up,” said Suezen Salinas, 31, who sought help at Legacy Community Health Services in Houston. “Apparently, there are a few glitches in the system, so it’s not letting us get past a certain place to be able to set up my profile and begin.” Salinas described herself as “disappointed, but I’m still excited.”

By midafternoon the Obama administration sought to quell the complaints from across the country.

Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services, contended problems were resolved and that consumers were, in fact, able to enroll. But during a telephone conference with reporters she refused to disclose a number, saying “we decided not to release that yet.”

Tavenner said 2.8 million people visited the federal healthcare.gov website since it opened Tuesday morning, but that it was unclear how many of those were repeat users.

“This is day one of a six-month process,” Tavenner noted, adding that people have until March 31 to enroll for insurance. Those who enroll by Dec. 15 will begin coverage on Jan. 1.

As the story notes, five times more than have ever been on the Medicare.gov website at one time were on healthcare.gov trying to use the exchanges. That’s truly incredible, and speaks very loudly to the deep, abiding need for this service. Just imagine for a minute how many more people could be getting coverage right now if the Republican Party hadn’t been engaged in a four year jihad to sabotage and undermine it at every step.

The Trib has a report that was updated a couple of times during the day that reported on some of the experiences folks had in Texas. This bit from their most recent update was really annoying to read.

The Brownsville Community Health Center had 50 people show up on Tuesday ready to sign up for health coverage — many even brought pay stubs and income documentation — but not a single one of them had an email address.

“If you don’t include an email address, they won’t let you through,” said Christela Gomez, the special projects coordinator and lead certification application counselor at the center. Although the center considered helping people sign up for an email account, Gomez said many weren’t comfortable with the idea because they did not have a computer to access the email address later. “Quite a few didn’t even know what an email address was,” she added.

The center’s certified application counselors helped the patients fill out paper applications, but they’ll have to wait for a written response from the federal government to find out whether additional documentation is needed or whether those applicants qualify for tax credits.

Some of the questions on the paper application were difficult for patients to answer, said Gomez. One man who came in to receive assistance finding health coverage currently works as a truck driver, she said. He earns 30 cents per mile, and his income can range from $50 to $100 a week.

“We didn’t really know how to fill in the income part with him,” she said, adding, “We kind of just wrote it in on the side, his situation.”

Paula Gomez, the executive director of the center, said her patients are mostly adults who are too young to qualify for Medicare. Although most of her patients have jobs, pay taxes and want to cooperate with the health care system, there are extenuating circumstances like language barriers that make it difficult.

“I’m sure there are pockets like ours all over the country,” Gomez said. She added that the federal government should be more flexible and consider the different situations people are facing across the country. “They think in terms of everything that’s going on in Washington, D.C., but they don’t look at the reality of the rest of the world in the United States,” she said.

You know what might have addressed that problem? If the state of Texas had created its own exchange, since the whole idea behind state-based exchanges was that local folks would know their interests and their population better than a bunch of distant bureaucrats in DC. If we lived in a state whose leaders cared about its people, that’s what we would have gotten. Instead, we’re stuck with the likes of Rick Perry, David Dewhurst, Greg Abbott, and the like, and this is the result. The fact that we’re using the federal exchanges here in Texas doesn’t mean that people won’t get signed up, and it doesn’t mean that they won’t be able to buy quality plans. But the experience could have been better, and it could have been more Texas-oriented, if Perry et al gave a damn. I understand politics, and I get doing what you can to screw your enemies. I don’t get screwing your own people.

Premiums for insurance exchange plans released

Guess what? They’re pretty darned affordable.

It's constitutional - deal with it

It’s constitutional – deal with it

“In just 99 days, millions of Americans will finally have the security and peace of mind that have eluded them for years,” U.S. Health and Human Services Secretary Kathleen Sebelius said on a press call, “as coverage starts to kick in on insurance purchased through the new health insurance marketplace.”

To help people comply with the individual health insurance mandate that takes effect on Jan. 1, the federal government will launch an Orbitz-style online marketplace on Oct. 1 for consumers to apply for tax credits and compare and purchase health plans.

According to the federal report released Tuesday night, Texas will have comparatively low premium rates for health plans offered in the federal marketplace compared with other states. The average monthly rate for a standard plan in the 48 states analyzed in the report was $328, while Texas’ was $305. Fourteen states and the District of Columbia will have lower rates on average than Texas for a standard health plan offered in the marketplace.

“Texas has historically had a reasonably competitive insurance market compared to some states,” said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight at the federal Centers for Medicare and Medicaid Services. He explained that in some states one insurance carrier may dominate 75 to 80 percent of the market. “Texas has not had that situation,” he said.

Texans will have on average 54 health plan options available in the federal marketplace. The number of available plans will vary depending on the region. For example, people in Austin will have 76 health plans to choose from on average, while people in the Rio Grande Valley will only have 30 options on average.

Four types of plans will be offered in the marketplace: Bronze, Silver, Gold and Platinum. In general, Bronze plans will have lower monthly premiums but higher out-of-pocket costs, while Platinum plans will have the highest monthly premiums but lower out-of-pocket costs. Premium rates and out-of-pocket costs will vary depending on age, the number of people in the household and the region in which the person lives, among other factors. Ultimately, the prices are based on the estimated cost of health care services over the course of a year.

People who have annual incomes between 100 and 400 percent of the federal poverty line will qualify for sliding-scale tax credits to help them purchase a health plan in the federal marketplace. For an individual, that’s an annual income of $11,490 to $45,960; for a family of four, it’s $23,550 to $94,200.

Click over to see some detailed information about what will be available in Texas, or click here to see the full report. Some highlights from the latter:

Individuals will have an average of 53 qualified health plan choices in states where HHS will fully or partially run the Marketplace

  • Individuals and families will be able to choose from a variety of bronze, silver, gold, and platinum plans in the Health Insurance Marketplace, as well as catastrophic plans for young adults and those without affordable options. Health insurance issuers can offer multiple qualified health plans, including multiple qualified health plan choices within a single metal level. In the 36 states in this analysis, the number of qualified health plan choices available in a rating area ranges from a low of 6 to a high of 169 plans. On average, individuals and families will have 53 qualified health plans to choose from in their rating area. Young adults will have an average of 57 qualified health plans to choose from, including catastrophic plans. The average number of choices will likely increase after including final data from state-based Marketplaces, which tend to have greater issuer participation.
  • On average, there are 8 different health insurance issuers participating in each of the 36 Marketplaces included in this analysis. This ranges from a low of 1 issuer to a high of 13 issuers within a state. About 95 percent of the non-elderly population in these 36 states lives in rating areas with 2 or more issuers. Roughly one in four issuers is offering health plans in the individual market for the first time in 2014.

Premiums before tax credits will be more than 16 percent lower than projected

  • The weighted average second lowest cost silver plan for 48 states (including DC) is 16 percent below projections based on the ASPE-derived Congressional Budget Office premiums.11 In 15 states, the second lowest cost silver plan will be less than $300 per month – a savings of $1,100 a year per enrollee compared to expectations. Overall, 95% of the uninsured potentially eligible for the Marketplaces live in states with average premiums below ASPE-derived CBO projected premiums (see Figure 1).
  • Young adults will pay lower premiums and also have the option of a catastrophic plan that covers prevention, some primary care, and high costs in cases of major accident or illness. The weighted average lowest monthly premiums for a 27-year-old in 36 states14 will be (before tax credits): $129 for a catastrophic plan, $163 for a bronze plan, and $203 for a silver plan. More than half of the uninsured potentially eligible for the Marketplaces live in a state where a 27-year-old can purchase a bronze plan for less than $165 per month before tax credits. There are an estimated 6.4 million uninsured Americans between the ages of 25 and 30 who may be eligible for coverage through Medicaid or the Marketplaces in 2014.

Premiums after tax credits

  • Tax credits will make premiums even more affordable for individuals and families. For example, in Texas, an average 27-year-old with income of $25,000 could pay $145 per month for the second lowest cost silver plan, $133 for the lowest cost silver plan, and $83 for the lowest cost bronze plan after tax credits. For a family of four in Texas with income of $50,000, they could pay $282 per month for the second lowest cost silver plan, $239 for the lowest silver plan, and $57 per month for the lowest bronze plan after tax credits.
  • After taking tax credits into account, fifty-six percent of uninsured Americans (nearly 6 in 10) may qualify for health coverage in the Marketplace for less than $100 per person per month, including Medicaid and CHIP in states expanding Medicaid.

It should be noted that it’s not all butterflies and lollipops, as Wonkblog explains.

Health experts say it is a good sign for consumers that premiums have come in lower than expected. Under the law, the plans must offer a basic set of benefits, including mental health and maternity care, which previously were not included in many private plans. Insurers are also forbidden from rejecting or charging people more because of preexisting conditions.

Many experts worried that those factors would drive up the cost of insurance. They partially credit competition on the marketplaces, where people will be able to directly compare plans from different insurance companies, for restraining premiums.

But they warn that premiums don’t tell the whole story.

The low rates are possible in part because insurance companies created special plans that include fewer in-network doctors and hospitals than many current plans.

This may not be a problem for healthy people who currently lack insurance. But those with illnesses may discover that their specialists are not covered by an exchange insurance plan. Low-income people accustomed to a certain community clinic may find that going there is no longer an option. And everyone may encounter long waits to see a doctor.

In addition, many of the lowest-cost plans may carry high deductibles, despite a cap imposed by the law that limits out-of-pocket costs to $6,350 per person per year.

“Despite the fact that the premiums are lower than expected, enrollees on exchanges are likely to face very high out-of-pocket costs before they hit their cap, and they are at risk of being in very narrow network plans that may or may not include all the providers they need access to,” said Caroline Pearson, vice president of health reform at the consulting firm Avalere Health, which did its own report on rates this month.

It’s still going to be a lot better than having no insurance, and for people who are currently paying exorbitant prices for individual plans, or who can’t get insurance at all because of pre-existing conditions, it will be awesome. That will include millions of Texans, some of whom are friends of mine, and all of whom Ted Cruz cares nothing about. Kevin Drum and the Kaiser Family Foundation have more.

Perry keeps asking for the same Medicaid waiver he hasn’t gotten in the past

Same as it ever was.

Corndogs make bad news go down easier

Free corndogs with every approved treatment!

Gov. Rick Perry is preparing for yet another battle in his war against Obamacare.

In a letter to the state’s health agency on Monday, the governor laid out his plan to request a federal waiver to reform Medicaid as Texas sees fit — without expanding eligibility.

“Seemingly, the president and his administration are content to simply throw money at a problem and hope that any problems will resolve themselves,” Perry wrote in a Monday letter to Kyle Janek, the executive commissioner of Texas’ Health and Human Services Commission. “My response, and the response of the Texas Legislature, has been crystal clear: Texas will not expand Medicaid under Obamacare.”

Instead, Perry has asked that the agency request flexibility in the form of a block grant — a fixed amount of money, rather than matching dollars for Medicaid services — from the federal government to fundamentally reform Medicaid. Specifically, Perry requested that the agency seek a waiver that allows the state to make changes to the program without receiving federal approval, continue asset and resource testing to determine eligibility, and initiate cost-sharing initiatives, such as co-payments, premiums and deductibles, among other reforms.

The waiver “should give Texas the flexibility to transform our program into one that encourages personal responsibility, reduces dependence on the government, reins in program cost growth and efficiently improves coordination of care,” Perry wrote.

[…]

In a second letter sent to HHSC on Monday, Perry requested that the agency develop a mechanism to continue collecting and analyzing income, asset and resource information on Texans who apply for Medicaid benefits. That’s despite a provision in the Affordable Care Act — one that takes effect on Jan. 1 — that requires the state to stop asset testing to determine Medicaid eligibility.

A copy of the letter requesting the block grant is here, and a copy of the letter on asset testing is here. Texas has been asking for a Medicaid block grant since at least 2008, when the Bush administration rejected the request. Perry knows full well what the answer will be, he’s just going through the motions out of spite and the continued delusion that he’ll be appealing to Iowa voters in 2016. If the CMS assigned me the task of writing the response, I’d start out by noting that in any negotiation, there must be good faith and a willingness to give something to get something. As the primary purpose of block granting Medicaid is the limit services, and the primary purpose of the Affordable Care Act is to enroll more people in health insurance plans, Perry’s proposal demonstrates neither of those things. Just this week, we’ve seen two examples of other Republican governors agreeing to expand Medicaid. They both wrung some concessions out of the feds in doing so, but the end result will be more people getting access to health care. And Lord knows, we need a commitment to providing access to health care in Texas.

Texas continued to have the highest rate of people without health insurance in 2012 at 24.6 percent, according to the Current Population Survey estimates released by the U.S. Census Bureau on Tuesday.

“Texas has often had the highest uninsured rate throughout the country,” said David Johnson, chief of the Census Bureau’s Social, Economic and Housing Statistics Division. He added that additional data from the American Community Survey that the Census Bureau plans to release later this week would provide more specific information on health insurance rates in states and metropolitan areas.

The Current Population Survey estimates revealed that the national uninsured rate declined in 2012, to 15.4 percent from 15.7 percent in 2011. The national real median income and official poverty rate were not statistically different in 2011 and 2012, according to the estimates.

Thanks to the insurance exchanges and the ACA subsidies, Texas’ unacceptably high level of uninsured people will decline, though as always Perry is doing everything he can to keep as many Texans as possible sick and unable to do anything about it. Perry and his fellow Republicans just don’t give a damn about the problem. Until they do, I see no reason for the feds to waste any time on these pointless requests.

People who don’t know about Obamacare can’t benefit from Obamacare

One suspects that’s the point.

It's constitutional - deal with it

It’s constitutional – deal with it

Texans, and in particular the state’s Hispanic population, might remain in the dark on the benefits of the new federal health care law because outreach efforts are largely focusing on the 24 states participating in the Medicaid expansion and state-based insurance exchanges, officials with the Centers for Medicare and Medicaid Services said [last] Monday.

Texas is not among those states; Gov. Rick Perry and Republican leaders have argued federal health reform would eventually bankrupt the state. But Dr. Olveen Carrasquillo, a member of the U.S. Health and Human Services Department’s Advisory Committee on Minority Health, said at a Monday meeting that just because a state like Texas isn’t expanding Medicaid or implementing a state-based health insurance exchange doesn’t mean it should be excluded from federal marketing aimed at Hispanics.

“We can’t pretend all is rosy,” he said. “I don’t think this communication plan is working.”

Two-thirds of Hispanics in the U.S. say they do not have enough information about the health reform law to understand how it will affect them, according to the Kaiser Family Foundation’s Health Tracking Poll. Texas has more Hispanic residents than any state but California, and without the Medicaid expansion, 22 percent of them will remain uninsured, according to the Urban Institute’s American Community Survey.

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Special federal funding known as navigator grants, which require at least one community-based nonprofit to operate as a health reform outreach provider, will become operational in Texas around September or October, according to Kelly Dinicolo, technical adviser at CMS. These nonprofits will provide in-person enrollment assistance to help people buy insurance — in Texas, it will be via a federal health insurance exchange — or direct them to Medicaid, if they qualify.

Dinicolo and other government officials said they have launched some limited advertising in Texas, but mainly through online marketing because it is easier to target a younger demographic. For those who do not have access to online information, CMS has announced a partnership with libraries to help people navigate the health reform changes.

The newly launched informational website about health care reform, Healthcare.gov, has also launched a Spanish version, CuidadoDeSalud.gov.

There’s also Be Covered Texas, in English and Spanish, which is a statewide campaign launched in March by Blue Cross Blue Shield Texas to help enroll Texans in the exchange, and Get Covered America, launched in June, aimed at informing people about the October 1 enrollment period opening. Hopefully, they can help to fill the gaps. But let’s be clear here: The reason we’re in this position is because 1) Rick Perry and most of the Republicans in the Legislature refused to expand Medicaid; 2) Perry and the Lege refused to do a Texas insurance exchange and have not lifted a finger to abet the federal effort; and 3) the Republican-controlled Congress has refused to appropriate any more money for the federal information program about exchanges. If people remain uncovered or uninformed despite the hard work of the people and groups heroically trying to overcome these obstacles, it’s not their fault.

What Obamacare will do for Texas

Even without Medicaid expansion, the Affordable Care Act will help millions of Texans get access to health care.

It’s constitutional – deal with it

Nearly 2.6 million Texans could qualify for tax credits to purchase health insurance in 2014, according to a report released Thursday by Families USA, a nonprofit that advocates for health care consumers.

The tax credits will be offered through the health insurance exchange — an Orbitz-style online marketplace for health insurance — that the federal government plans to launch as part of the Affordable Care Act in October. Beginning in January, families with an income of up to 400 percent of the federal poverty line, between $47,100 and $94,200 for a family of four, will be eligible for a tax credit subsidy to purchase insurance through the exchange. The tax credits will be offered on a sliding scale, so that lower-income families will receive larger credits.

“These are typically the families where folks are working, sometimes more than one job,” U.S. Rep. Pete Gallego, D-Alpine, said of the report. “Regardless of where you are on the political spectrum, I think that’s something we can all support.”

Nearly 5.8 million Texans — nearly a quarter of the state’s population — are uninsured. The Health and Human Services commission estimates the tax credits offered through the health insurance exchange and other provisions in the Affordable Care Act will lower that rate to 16 percent. If Texas also expanded Medicaid — an unlikely scenario given Gov. Rick Perry’s opposition — the uninsured rate could be lowered to 12 percent.

“Given the large number of people in Texas that are uninsured, many of whom are poor, this is an extraordinary opportunity,” said Ron Pollock, executive director of Families USA. He said it was “short-sighted” for the state’s leadership to oppose Medicaid expansion, as it would bring billions of federal dollars to the state, and increase job opportunities.

You can see the report for Texas here, and for other states here. That still leaves about a million people who would be able to get Medicaid if the state agrees to expand it, but we know how little Rick Perry cares about these people. Trail Blazers has more on the Families USA report.

Elsewhere on the Medicaid front, HHSC Commissioner Kyle Janek has been given the go-ahead to negotiate with the U.S. Centers for Medicare & Medicaid Services. At the time, he wasn’t given any direction about what to negotiate for or toward, but perhaps now that the Zerwas bill has been discussed in committee there’s something tangible for him to talk about. We’re unlikely to hear much about his effort and any progress he may make since apparently talking about it in public spooks people, the way saying the name “Voldemort” does in the Harry Potter books. Lord only knows what might happen, but hey, at least they’re talking. EoW has more.