Michigan Family Connections Fall 2017 News

Michigan Family Connections Fall 2017 newsletter is a publication of the Michigan Family to Family Health Information Center and the Family Center for Children and Youth with Special Health Care Needs Family [phone Line 800-359-3722]. Here are two items that will help families seeking medical and other benefits for their special needs children:

ACA OPEN ENROLLMENT IS GOING ON NOW—DON’T WAIT! 

With so much uncertainty around the Affordable Care Act, some individuals and families are waiting to see what happens. But it is important to note that there are important deadlines to meet if you need to purchase coverage. Don’t wait and take a chance on missing out on enrollment.

The Kaiser Foundation recently did an analysis on individuals eligible for Marketplace insurance. The results show that 54% or 5.9 million people who are uninsured and eligible to purchase coverage on the Marketplace would pay less in premiums than they would owe as a penalty for lacking coverage.

Within that, about 4.5 million (or 42%) could obtain a bronze level plan at no cost in 2018, after taking income-related premium tax credits into account. For more information on the results of this analysis, go to the Kaiser Foundation website here
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For more information, or for assistance in finding help with enrollment, please visit: www.healthcare.gov .

December 15, 2017—Enrollment closes

For individuals who enroll during this open enrollment period, coverage will begin on Jan 1, 2018.

MICHIGAN MILITARY FAMILY SPECIAL NEEDS COALITION

The Michigan Military Family Special Needs Coalition was recently formed as a partnership between the State Family Program Office, and Michigan military families with special needs. The purpose of the Coalition is to improve support and gather resources for all military and veteran families in Michigan requiring medical or educational consideration for family members. A family member with special needs is defined as a:

• Spouse, child or incapacitated adult, who, regardless of age, has special medical needs and requires medical care for a chronic condition, receives ongoing services from a medical specialist or has significant behavioral health concerns. 
• Child (birth through age 21) with special education needs who is eligible for, or receives, either early intervention services through an individualized family service plan, or special education services through an Individualized Education Program. 

The Coalition is seeking any Michigan military service members, veterans, or family members who want to assist in improving support and resources for our Michigan military and veteran families with special needs.

Please share this information with any military or veteran family with special needs that may be interested in participating. Any service members or family members interested may contact Jess Ulrey at (517) 481-8301. You can also visit their Facebook page at: https://www.facebook.com/mmfsncoalition/  .

Health Care in Flux: Executive Orders and Federal Regulations

President Trump, with great flourish, signed an Executive Order on October 12, 2017 that, if and when it is implemented, will expand lower-cost insurance options under the Affordable Care Act or Obamacare.

This action is separate from the decision by Trump to cut off payments to insurance companies to subsidize moderate to lower income policy holders who buy insurance through the ACA exchanges. This action has an immediate effect, unlike the signing of the Executive Order that calls for changes to healthcare regulations. The process of changing federal regulations can take months to years to implement.

An article in Kaiser Health News (KHN), “Trump’s Order Advances GOP Go -To Ideas To Broaden Insurance Choices, Curb Costs”, by Judy Appleby, 10/12/17, explains the intent of this particular order as well as other details including the pros and cons:

“The Trump administration Thursday advanced a wide-ranging executive order aimed at expanding lower-cost insurance options, allowing employers to give workers money to buy their own coverage and slowing consolidation in the insurance and hospital industries.

“Critics said that, if implemented, the changes could result in more bare-bones coverage and pull healthier people out of the already struggling insurance markets, leading to higher premiums for those who remain in more-regulated coverage.

“President Donald Trump’s action, which will not take effect in time to affect the upcoming open enrollment for coverage in 2018, signals a shift in the administration’s strategy, which relied on Congress to repeal the Affordable Care Act. Trump is now using the force of his executive rule-making authority to implement long-favored GOP policy alternatives.” [emphasis added]

Before there is widespread panic that millions will immediately lose their health insurance, the good news is that it will take some time before that happens and perhaps agreements between Congress and the President to shore up Obamacare will occur before this policy can go into effect. The bad news is that judging by the current state of this debate, such an agreement is highly unlikely.

What is an Executive Order?

This is from Wikipedia:

Executive Orders are presidential directives issued by United States Presidents and are generally directed towards officers and agencies of the U.S. federal government. Executive orders may have the force of law, if based on the authority derived from statute or the Constitution itself. The ability to make such orders is also based on express or implied Acts of Congress that delegate to the President some degree of discretionary power (delegated legislation).[1]

Like both legislative statutes and regulations promulgated by government agencies, executive orders are subject to judicial review and may be overturned if the orders lack support by statute or the Constitution.[2] Major policy initiatives require approval by the legislative branch, but executive orders have significant influence over the internal affairs of government, deciding how and to what degree legislation will be enforced, dealing with emergencies, waging wars, and in general fine-tuning policy choices in the implementation of broad statutes.

If you have doubts about whether Wikipedia is an authoritative source of information, that depends on the subject. This entry jibes with what I have read before about executive orders and I’m sure there are many other authoritative sources to confirm the information.

How does the federal rule making process work and what does this have do with you?

There’s nothing like a civics lesson to take your mind off the horrifying prospect that your family member with a disability and who-knows-how-many pre-existing conditions, could be priced out of health insurance or denied it altogether.

One way that people with disabilities and their families can have an impact on proposed changes to healthcare is through opportunities afforded for public comment during the rule making process.

“The Guide to the RulemakingProcess”, prepared by the Office of the Federal Register, is a handy tool for individuals and organizations that want to follow and comment on proposed changes to federal regulations.

Here is another handy definition from Wikipedia:

“The Federal Register, abbreviated FR or sometimes Fed. Reg., is the official journal of the federal government of the United States that contains government agency rules, proposed rules, and public notices.[1] It is published daily, except on federal holidays. The final rules promulgated by a federal agency and published in the Federal Register are ultimately reorganized by topic or subject matter and codified in the Code of Federal Regulations (CFR), which is updated annually.”

Here are a few excerpts from “The Guide to the Rulemaking Process” that will help assure your participation:

How does an agency involve the public in developing a proposed rule?

An agency may take some preliminary steps before issuing a proposed rule. They gather information through unstructured processes and informal conversations with people and organizations interested in the issues. If an agency receives a “Petition for Rulemaking” from a member of the public, it may decide to announce the petition in the Federal Register and accept public comments on the issue.

An agency that is in the preliminary stages of rulemaking may publish an “Advance Notice of Proposed Rulemaking” in the Federal Register to get more information. The Advance Notice  is a formal invitation to participate in shaping the proposed rule and starts the notice‐and-comment process in motion.

Anyone interested (individuals and groups) may respond to the Advance Notice by submitting comments aimed at developing and improving the draft proposal or by recommending against issuing a rule. Some agencies develop proposed rules through a negotiated rulemaking. In this process, an agency invites members of interested groups to meetings where they attempt to reach a consensus on the terms of the proposed rule. If the participants reach agreement, the agency may endorse their ideas and use them as the basis for the proposed rule.

What is the role of the President in developing a proposed rule?

Before a proposed rule is published in the Federal Register for public comment, the President, as head of the Executive branch, may take the opportunity to review the rule. The President is assisted by the Office of Information & Regulatory Affairs (OIRA), which analyzes draft proposed rules when they are “significant” due to economic effects or because they raise important policy issues. For significant rules, the agency must estimate the costs and benefits of the rule and consider alternate solutions….

What is the purpose of the proposed rule?

The proposed rule, or Notice of Proposed Rulemaking (NPRM), is the official document that announces and explains the agency’s plan to address a problem or accomplish a goal. All proposed rules must be published in the Federal Register to notify the public and to give them an opportunity to submit comments. The proposed rule and the public comments received on it form the basis of the final rule.

What is the time period for the public to submit comments?
 

In general, agencies will specify a comment period ranging from 30 to 60 days in the “Dates” section of the Federal Register document, but the time period can vary. For complex rulemakings, agencies may provide for longer time periods, such as 180 days or more. Agencies may also use shorter comment periods when that can be justified.

Members of the public may request that the agency allow more time to submit comments, and agencies may consider late‐filed comments, if their decision‐making schedule permits it. Commentors should be aware that agencies generally are not legally required to consider late filed comments. Agencies usually provide information in the proposed rule and/or their procedural rules indicating whether they will consider late‐filed comments.

Do agencies have additional options for gathering public comments?

During the comment period, an agency may also hold public hearings where people can make statements and submit data. Some agencies operate under laws that require rulemaking hearings. Others may hold public meetings to collect more information or to help affected groups get a better understanding of the proposed rule. Many agencies are beginning to use webcasts and interactive Internet sessions to broaden the audience attending public meetings.

After the comment period closes, an agency may establish a second period for reply comments (comments that respond to prior comments). A reply period is not required by law. The reply comment period enables people to respond to comments that agencies received at the end of comment period, creating more of a public dialog.

How do public comments affect the final rule?

The notice‐and‐comment process enables anyone to submit a comment on any part of the proposed rule. This process is not like a ballot initiative or an up‐or‐down vote in a legislature. An agency is not permitted to base its final rule on the number of comments in support of the rule over those in opposition to it. At the end of the process, the agency must base its reasoning and conclusions on the rulemaking record, consisting of the comments, scientific data, expert opinions, and facts accumulated during the pre‐rule and proposed rule stages.

To move forward with a final rule, the agency must conclude that its proposed solution will help accomplish the goals or solve the problems identified. It must also consider whether alternate solutions would be more effective or cost less.

If the rulemaking record contains persuasive new data or policy arguments, or poses difficult questions or criticisms, the agency may decide to terminate the rulemaking. Or, the agency may decide to continue the rulemaking but change aspects of the rule to reflect these new issues. If the changes are major, the agency may publish a supplemental proposed rule. If the changes are minor, or a logical outgrowth of the issues and solutions discussed in the proposed rules, the agency may proceed with a final rule.

How is the final rule structured?

Final rules also have preambles, including the summary, effective date, and supplementary information. The final rule published in the Federal Register begins with a “Summary” of the societal problems and regulatory goals and explains why the rule is necessary.

Every final rule must have an “Effective Date.” However, any portions that are subject to later approval under the Paperwork Reduction Act or are subject to Congressional approval may be excepted from that effective date. The “Dates” caption in the Federal Register may also contain compliance or applicability dates.

The agency must state the “basis and purpose” of the rule in the “Supplementary Information” part of the preamble. This statement sets out the goals or problems the rule addresses, describes the facts and data the agency relies on, responds to major criticisms in the proposed rule comments, and explains why the agency did not choose other alternatives.

The agency must identify its legal authority for issuing the rule and publish the regulatory text in full. The regulatory text sets out amendments to the Code of Federal Regulations (CFR). Each amendment begins with instructions for changing the CFR.

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Despite the promise of public involvement in federal rulemaking, there has not been any inclination on the part of the President or the majority in Congress to solicit opinions or advice from the general public, or even from people directly affected by proposed changes in healthcare policy. It is hard to tell where all this leading. The best advice is to Expect the Unexpected.

Kaiser Health News on the effort to replace Obamacare

A renewed effort to replace Obamacare is moving forward, but this time there is a shorter time-limit for passage. The proposed Graham-Cassidy bill in the U.S. Senate could pass by September 30th, 2017 with a simple majority of votes, but after October 1st, 2017, the beginning of the new fiscal year, the Republicans would need 60 votes to pass the bill under Senate rules. Based on the unpopularity of previous bills this year to Replace and Repeal Obamacare, this would very likely be an insurmountable obstacle for passage.

Here is an excerpt from an article in Kaiser Health News (KHN), "Last-Ditch Effort By Republicans to Replace ACA: 5 Things You Need to Know" by Julie Rovner, 9/19/17:
...

Here are five things to know about the latest GOP bill: 

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices.

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill.

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letterto Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Update on Health Care/Medicaid votes in the U.S. Senate

From the national ARC news letter, Capitol Hill Insider for the week of July 24th, 2017:

Health Care/Medicaid - Senate Vote on Health Care Repeal Planned for This Week

The Senate continues to try and move forward on a plan to repeal the Affordable Care Act (ACA). On July 17, plans to repeal the ACA and cap Medicaid were put on hold when four Republican Senators announced their intent to vote "no" on a motion to begin debate. The next morning, Senate Majority Leader Mitch McConnell (R-KY) announced that there would be a vote on Obamacare Repeal Reconciliation Act (ORRA), which does not include Medicaid per capita caps, but does repeal Medicaid expansion, the increased federal match for the Community First Choice option, the individual and employer mandates, the premium tax credits, and a number of other provisions. The bill would not take effect for two years, giving Congress time to develop a replacement. However, it is unclear whether insurers will continue to participate in the market when the long-term framework is unknown. Within hours of this announcement, three Republican Senators announced their opposition to voting to repeal and delay replacement with a new plan.

Senate Majority Leader McConnell then announced that there will be a vote on a motion to begin debate early this week. It is unclear whether the vote will be on the ORRA or a revised Better Care Reconciliation Act (BCRA). The Senate is also considering revising BCRA to includes $200 billion in non-Medicaid funds for expansion states in an effort to win support from Senators from the Medicaid expansion states. The Congressional Budget Office has evaluated the ORRA and BCRA and found that they will increase the number of uninsured Americans by 32 million and 22 million, respectively.

To further complicate the situation, the Senate Parliamentarian, who must review provisions to make sure they comply with the Senate rules, has found that several provisions could be challenged and would require 60 votes to keep them in the bill. The provisions include a prohibition of Planned Parenthood funding, ending the essential health benefits requirement in Medicaid, continuing funding for cost sharing subsidies, allowing states to change the requirement that plans spend at least 80% of premium income on health care, and the six- month waiting period prior to enrollment without continuous coverage. The Parliamentarian continues to review the bill and may issue additional findings. It is unclear if the Senate has the votes to pass any legislation at this point, but the leadership is expected to keep working to try and find agreement on repealing the ACA.

Navigating Health Care Reform

Prickly Hearts

We are fortunate in not having to deal with changing health insurance. Our sons have been covered by Medicaid since they were 18 years old in a Medicaid friendly part of Michigan. Medicaid also pays for the services they need as developmentally disabled adults. Medicaid expansion should help more children and adults with disabilities qualify for mental health services if they have mental illness or  DD.

Last Sunday, 3/23/14, The Detroit Free Press published a whole section on navigating health care reform with about 50 links to articles on just about every topic concerning the Affordable Care Act and obtaining health insurance you could imagine. Here is the introduction to the On-Line version of the DFP's special health care section:

Are you ready?
 
The most contentious piece of federal health reform legislation – a requirement that every person have health insurance by next year or face tax penalties – has begun. It is officially named the Patient Protection and Affordable Care Act, although some groups refer to the legislation as just the Affordable Care Act, ACA or "Obamacare." The enrollment period began October 1 and runs through March 31. Many Michigan residents will be able to buy insurance through the Michigan Health Insurance Marketplace, an online exchange where the coverage may be more affordable. If you have questions, let us know and we'll try to find answers. Write: healthreform@freepress.com.

Good luck to those who have not yet signed up for a workable health insurance policy.

Affordable Care Act : Michigan health plans and coverage for special needs children

This is from the Detroit Free Press, 9/12/13, on "What Michigan health plans must offer" under the Affordable Care Act: 

• Ambulatory patient services.
• Outpatient care that includes visits to primary care doctors, home health care services and hospice care, though some carriers might limit this to no more than 45 days.Emergency service.
• Visits to the emergency room and ambulance transportation.Hospitalization.
• Surgeries, transplants and care in a skilled nursing facility, though some carriers may limit the latter to no more than 45 days.Maternity and newborn care: Prenatal care, delivery and postnatal care.
• Inpatient and outpatient mental health and substance abuse services: Some carriers may limit this to 20 days each per year.
• Prescription drugs: Includes commonly prescribed drugs and specialty drugs, a class known for its extraordinary high cost per dosage.
• Rehabilitative and habilitative services and devices: Allows 30 visits per year for physical therapy, occupational therapy or chiropractor services, 30 visits for speech therapy and 30 visits for cardiac or pulmonary rehab.
• Laboratory services: X-rays, CT scans and breast cancer diagnosis tests.
• Preventive and wellness services: Chronic disease management and immunizations.
• Pediatric services: Oral and vision care and more.

[Source: Detroit Free Press research]

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For special needs children, the Catalyst Center has published a document called "The Affordable Care Act - A side-by-side comparison of major provisions and the implications for children and youth with special health care needs from the Catalyst Center". The center is "a national center dedicated to improving health care coverage and financing for Children and Youth with Special Health Care Needs (CYSHCN)". This publication gives a detailed description of what is required by the ACA, the provisions that are already in effect, soon to be implemented provisions, and the implications for children with special needs.