Saturday, August 31, 2013

Michigan expands Medicaid to low-income people

Here two detailed articles from the Detroit Free Press on the vote by the Michigan Senate to expand Medicaid to cover people earning up to 133% of the poverty level. The first article, "Medicaid expansion passes after heated politicking; 470,000 more Michiganders to get coverage", 8/27/13, covers the nitty gritty and sometimes unseemly wheeling and dealing that it took to get the bill passed. The second article, "Delay in Medicaid expansion to be costly" deals with the consequences of the failure to get a two-thirds majority of the Senate to agree that the bill should take immediate effect. Both articles are by Kathleen Gray from the Detroit Free Press Lansing Bureau.

The passage of Medicaid expansion allows the state to take advantage of extra federal funding available under the Affordable Care Act to cover low-income people. Although the Michigan Senate voted to approve Medicaid expansion, there's a catch. The bill will not take effect until April 1, 2014. This could change after the Michigan legislature comes back in September, if two-thirds of the Senate can agree that it should take effect immediately (meaning on January 1, 2014). If the the legislature fails to pass the bill by a two-thirds majority, the state will have to forgo an estimated $7 million per day in federal funds that would have covered health care for this low-income population.

The effect of Medicaid expansion on adults with developmental disabilities will not be as great as the effect on people with mental illness, although low-income families with disabled children would be likely to benefit from Medicaid expansion. The vast majority of adults with developmental disabilities already meet the eligibility criteria for Medicaid, but many people with mental illness who can work, at least sporadically, have a harder time qualifying. Medicaid expansion will provide Medicaid to mentally ill people who meet the income criteria and also make them eligible for Medicaid-funded mental health services. It should also have a significant impact on low-wage caregivers who do not currently have health insurance.

One reason the bill won enough Republican support to pass was offered by State Senator Kahn: “This bill is about reform. It is a national model,” Kahn said. “The taxes in the Affordable Care Act are billions of dollars. And for us in Michigan, it will be $2 billion siphoned from our people, and we’re going to bring that back to the state.” 

Here is addtional information on Medicaid expansion, according to the Detroit Free Press:
  • Federally-funded Medicaid expansion will cover 320,000 low-income Michiganders next year and 470,000 people by 2020.
  • "The bill requires the additional recipients [of Medicaid] to contribute 5% of their out-of-pocket medical costs. After 48 months, that co-pay would increase to 7% or the recipient could purchase insurance on the health care exchange...if a person who falls in that poverty level is determined to be “medically frail” — either with a chronic disease, mental illness or are unable to complete the daily tasks of life — they would remain at the 5% co-pay."
  • The federal government will have to grant waivers to Michigan for two of the provisions of the bill, the creation of health savings accounts for Medicaid recipients and language that allows recipients to choose between a health care exchange or Medicaid benefits after 48 months. 
  • The Medicaid expansion will be fully paid for by the federal government through 2017. The federal contribution would drop to 90% by 2020.

Tuesday, August 13, 2013

When more costs less: more and better psychiatric care reduces overall costs

An opinion piece in the New York Times, (8/3/13) by Christine Montross entitled "The Woman Who Ate Cutlery" illustrates the point that trying to save money by making care and treatment for people with mental illness less accessible, does not save anything. Emergency rooms become the only available treatment venue in a crisis - a poor substitute for preventive care before a crisis develops, hospitalizations increase, and sometimes lives are lost.

Problems in the the system of care for people with mental illness often parallel those for people with developmental disabilities. There are many people with developmental disabilities who have unusual and sometimes dangerous behaviors, with the added complication that the person's capacity to communicate their frustrations make it even more difficult to know how to relieve their distress. There are also people with DD whose medical problems, when not addressed early or treated appropriately, can land them in the emergency department with the result that the person receives too little or too much treatment that is almost always more costly than it needs to be.

In "The Woman Who Ate Cutlery", "M" is an extreme case - a woman who ingests knives and forks and other sharp objects and inserts objects and substances into her body to relieve stress caused by mental illness. 

According to the article:
  • "If M had insurance, or enough money to pay out of pocket, she might see a therapist every week for an hour and a psychiatrist once or twice a month. Instead, she’s treated by an overextended, publicly funded mental-health center where she sees a psychiatrist for 20 minutes, four times a year. Not surprisingly, her symptoms persist and she is hospitalized again and again."
  • "…Our failure to provide a critical, basic level of outpatient psychiatric care to the mentally ill creates a volatile cycle in which uninsured or underinsured patients avail themselves of treatment only when they are in crisis. This is analogous to refusing to treat hypertensive patients — or to monitor their blood pressure — unless they show up in the E.R. after having had a stroke."
  • "…If M had a regular outpatient psychiatrist, she could call him or her in these moments of distress, schedule an urgent appointment, and obtain treatment and care from a simple phone call. But M does not have a relationship with a provider; she has a relationship with an institution. And the institution requires that M be in imminent danger in order to be treated."
  • "…According to Dr. E. Fuller Torrey, president of the national nonprofit Treatment Advocacy Center, 'Assisted outpatient treatment has proven to reduce psychiatric hospitalizations by more than 70 percent.'"
Montross concludes, "…we will need to place new societal value on the importance of mental health. Until accessible, affordable mental-health care is a universal right, too many psychiatric patients will continue to receive the reactionary, crisis-driven care that is all our emergency rooms are equipped to provide."

Up North and on Vacation: August 2013

It can be cold up here, even in August. As we were sitting huddled around the fireplace, throwing logs on the fire, this song from the 1970s came to mind. Here it is sung by Tompall Glaser. Lyrics are by Shel Silverstein. This has nothing to do with my personal life, but parts of it ring true for people I know.

Tuesday, August 6, 2013

Michigan Medicaid Reform Proposals before the State Senate

This is from the August 2013 newsletter, The Advocate, from The Area Agency on Aging 1-B. AAA 1-B is a nonprofit agency serving the needs of older adults in Livingston, Macomb, Monroe, Oakland, St. Clair, and Washtenaw counties. 


Three Medicaid Reform Proposals Move to Full Senate for Consideration, Vote Likely in Early September  

On July 24th, the Senate Medicaid workgroup convened by Majority Leader Randy Richardville (R-Monroe) and led by Senator Roger Kahn, M.D. reported three Medicaid reform proposals; HB 4714 as passed by the House on June 13 with minor changes, SB 422 (Caswell) known as the Michigan Low-Income Health Plan Act, and Senate Bills 459 and 460 (Colbeck) known collectively as the Patient-Centered Care Act. All three bills were sent to the Senate Government Operations Committee and were voted out of committee on July 31st to be sent to the Senate for full consideration, debate and a likely vote will happen in early September.

The decision to move all three Medicaid proposals out of committee for a full senate vote was made by Senate Leader and Government Operations Committee Chair Randy Richardville citing that all three bills have their own merits. Supporters of HB 4714 worry the additional proposals may strip potential votes in favor of SB 422, or 459 and 460.

HB 4714 (S-7): The Healthy Michigan Plan reforms Medicaid to cover individuals with incomes up to 133% of the federal poverty level for up to 48 months with a requirement that the newly insured would pay no more than 5% of their out-of-pocket medical expenses. Following the 48 month period, the newly insured could then remain on Medicaid with an increase in their copayments up to 7% or they could choose to purchase health coverage through the Federal Health Care Exchange.

SB 422: The Michigan Low-Income Health Plan Act would essentially create a state funded alternative to Medicaid. The Act would provide tax credits to those between 133% and 100% of Federal Poverty Level (FPL) to enable the purchase of insurance on the healthcare exchange established by the Affordable Care Act. This bill establishes a Michigan Low-Income Health Plan which would provide health coverage to persons who meet the following criteria; Not eligible for Medicare, Medicaid, or MIChild; Household in-come under 100% of FPL; Under age 65; Not eligible for veterans health benefits; and have no other health insurance coverage.

SB 459, 460: The Patient-Centered Care Act would require the state to license private health exchanges, create the Low-Income Trust Fund, and “migrate” Medicaid recipients to individual health savings accounts from which they could purchase a qualified health plan. The Low-Income Trust Fund would be used to fund the deductibles of former Medicaid or MIChild recipients until the balance of their health savings account is adequate to pay their deductibles.

HB 4714 S-7 closely mirrors the version passed by the house in June and is likely to draw the majority of bipartisan support. Both alternative plans SB 422 and SB 459, 460 are receiving criticism as too costly to the State’s general fund, or as unfeasible given the knowledge and personnel requirements needed to administer the program.

Contact your Senator to share your opinion on reforming Medicaid in Michigan