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This week’s updates
Headlines of the week
![threats]( "threats") Threats and rhetoric around health reform persist at the Colorado General Assembly
A bill introduced in the Colorado General Assembly would repeal the law establishing Colorado’s Health Insurance Exchange if the U.S. Supreme Court declares any part of the Patient Protection and Affordable Care Act unconstitutional. Senate Bill 12-053 is sponsored by Sen. Tim Neville, R-Littleton, and Rep. Marsha Looper, R-Calhan. The bill establishing the exchange passed last year, and Colorado was the only state to pass such a law with bipartisan support.
The Colorado Health Benefit Exchange will offer a competitive marketplace where individuals and small businesses can purchase health insurance. Find more information about the exchange in previous editionsof the Health Law and Policy Update.
![colorado]( "colorado") Colorado House passes resolution to repeal health reform law
A Colorado House Joint Resolution calling for a federal constitutional convention to repeal the Patient Protection and Affordable Care Act passed the House on Thursday. It is another in a series of efforts to repeal the law debated over the past two years by the Colorado General Assembly. The bill is unlikely to pass the Colorado Senate. The U.S. Supreme Court will hear oral argument on the constitutionality of the health reform law in March and is expected to issue a decision by the end of June.
Repealing health reform – and its vital consumer protections – would have a devastating effect on the tens of thousands of Coloradans who are benefiting from the law and countless more who will benefit from continued implementation. Thanks to the Affordable Care Act:
- Parents of children with pre-existing conditions are able to purchase insurance for their children.
- Insurance companies may no longer impose lifetime limits on coverage.
- Annual limits are phasing out.
- Companies cannot drop customers from coverage if they get sick.
- Children can be covered under their parent’s policies until they reach age 26.
- Colorado’s seniors have access to no-cost preventive services, are receiving help with the cost of prescription drugs and, by 2020, will no longer have to worry about the “donut hole” gap in prescription drug coverage.
- Colorado’s high-risk pool for people who cannot get insurance, GettingUsCovered, has more than 1,000 enrollees.
FamiliesUSA has compiled a complete list of reforms that have already gone into effect. An issue brief the Colorado Center on Law and Policy released in March 2011 reviews how the reforms played out in Colorado.
![health]( "health") Health care attorney joins CCLP
Health Care Attorney George Lyford joined the Colorado Center on Law and Policy’s Health Care Program team this month. Lyford previously worked as a staff attorney for the Health Care Access Program at Nebraska Appleseed Center for Law in the Public Interest and as an attorney for Mary Kay Hansen Law & Mediation. Lyford earned a law degree from the University of Nebraska College of Law. Reach him by e-mail or at 303-573-5669, ext. 310.
![university]( "university") University of Colorado Hospital will negotiate to run Memorial Health System
The Colorado Springs City Council on Jan. 10 voted to proceed with negotiations for University of Colorado Hospital to run city-owned Memorial Health System. The move is a significant step toward shifting management control of one of the state’s largest hospital systems. Memorial Health System has been overseen by a panel appointed by the City Council.
University of Colorado Hospital was one of several bidders seeking control of the Colorado Springs system. The university hospital proposes to add Memorial to a new University of Colorado Health System, which will also include Fort Collins-based Poudre Valley Health System and Denver-based Children’s Hospital Colorado. The university hospital is seeking a 30-year lease of Memorial.
Once a lease is negotiated, and the City Council approves it, the plan would be subject to an election of city voters, likely late this year. The Gazette newspaper of Colorado Springs offers an overview of how the deal has developed.
The Colorado Center on Law and Policy has urged the City Council to ensure any lease with University of Colorado Hospital includes a commitment to maintain Memorial’s level of charity care. A letter CCLP sent Jan. 5 to City Council President Scott Hente outlines the agency’s concerns, which CCLP Special Counsel Ed Kahn also expressed in anarticle posted on the Health Policy Solutions website.
![report]( "report") Report focuses on building links between Medicaid, exchanges and individual market
A new report from the National Academy of Social Insurance highlights the importance of ensuring a seamless continuation of coverage for individuals who move between eligibility for Medicaid and tax subsidies offered through health insurance exchanges to be operational by 2014.
Under the Patient Protection and Affordable Care Act, various affordability programs will help individuals gain access to coverage. Those include Medicaid, Children’s Health Insurance Program (CHIP), advance premium tax credits and cost-sharing reductions available in the exchanges. However, the report states, “more than a third of all adults with family incomes below 200 percent of the federal poverty level can be expected to experience sufficient income fluctuation to shift from Medicaid to the Exchange or the reverse.” That fluctuation could result in interruptions in treatment and providers, which might lead to ineffective treatment or even ceasing treatment altogether.
The authors note that states have a great deal of flexibility in determining how to integrate Medicaid, CHIP, the exchanges and individual market. States, including Colorado, are faced with decisions regarding to what extent providers and health plans participate between markets (Medicaid, the exchange, or the individual market). Those decisions will affect an individual’s ability to continue treatment with his or her doctor, regardless of changes in eligibility. The authors conclude ensuring a seamless continuation of coverage “begins with the establishment of a coordination mechanism at the state level, governed by the agencies involved in coordination and inclusive of the stakeholder interests in a more unified operation.”
What’s next
![hcpf]( "hcpf") HCPF announces a series of regional outreach meetings
State health policy officials are trying to alert residents to important changes in the Medicaid program by holding meetings across the state. The Department of Health Care Policy and Financing (HCPF) is holding the meetings to discuss the Medicaid expansion to adults without dependent children whose incomes are up to 10 percent of the federal poverty level, the new Medicaid buy-in program for adults with disabilities and Colorado PEAK (the online application for public benefits). The two new Medicaid programs will be implemented this spring.
The meetings begin Jan. 30 in Glenwood Springs and will continue through February. There will also be several webinars in February and the beginning of March. The department is asking for advance registration.Find details on a flier.
HCPF’s Medical Services Board on Jan. 13 approved the final eligibility rule changes for the plan to allow Medicaid eligibility to some adults without dependent children. People with incomes up to 10 percent of the federal poverty level will be eligible, and the program will be capped at 10,000 participants. Applicants may begin submitting applications April 1, and the department plans a lottery in May to fill the spots.
Advancing the debate
![medicaid]( "medicaid") Medicaid history
We thought it would be useful as we move into a legislative session that will focus on the value and role of the Medicaid program in Colorado to give you some background about the program.
Medicaid and Medicare were signed in to law by President Johnson in 1965. The Act, which passed by a large bi-partisan majority, was hailed as an enormous step forward for the nation. President Johnson upon signing the bill into law said:
Many men can draft many laws. But few have the piercing and humane eye which can see beyond the words to the people that they touch. Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of health to the old and to the poor. And fewer still have the courage to stake reputation and position, and the effort of a lifetime upon such a cause ….
Because the need for this bill is plain, and it is so clear indeed that we marvel not simply at the passage of this bill, but what we marvel at is that it took so many years to pass it.
The full text is posted online.
Medicaid was designed to serve two primary functions – the program offers medical insurance to those poor enough to qualify for cash assistance and complements the Medicare program by paying for long-term care for people without resources. Over the years, Medicaid has continued to insure the poor and pay for long-term care for the disabled and elderly. Medicaid eligibility as well as the services and benefits offered under the program expanded as our nation grew more interested in and aware of the long term benefits of offering preventive care and treatment for children and pregnant women, as we came to value home and community based long term care, and as we realized that seniors could not access Medicare benefits if they were unable to pay Medicare premiums and copayments.
Medicaid also has played its intended role by shoring up those losing jobs and health insurance during recessions – we have seen that play out these last few years in Colorado as our Medicaid roles have expanded significantly. Finally, Medicaid contributes substantially to states’ economies by bringing in billions of federal dollars. What follows are some key milestones in the program nationally and in Colorado. Where we go from here and whether we honor the intent of a law, which President Truman said “puts this Nation right where it needs to be, to be right” will be the subject of much debate and discussion over the next few months.
Some key milestones:
1965 – the program mandated coverage for certain populations, including families receiving cash assistance as well as certain services including physician, inpatient and outpatient hospital care, lab and x-rays and skilled nursing facility care. States had the option to cover other populations and services and receive a federal match for doing so. From the beginning, Medicaid supplemented the Medicare program by covering long term care. Medicaid was initially administered by the Social Rehabilitative Administration which focused on poverty and welfare programs.
1967- EPSDT (Early Periodic Screening Diagnostic and Treatment) services were added to Medicaid. EPSDT ensures that children receive screening and treatment for all medically necessary services until age 21. This was the era when policy makers began to recognize that children living in poverty were exposed to environmental hazards (like lead paint) and had inadequate access to basic and preventive care. The growing recognition that many conditions could be cured or ameliorated by screening (for example for lead exposure) and cured by early diagnosis and treatment was the impetus behind EPSDT. In 1989, EPSDT was expanded to require coverage for services even if those services were not covered for Medicaid adults.
January 1969 – Colorado establishes a Medicaid program. By 1972 all states are participating in the program, except for Arizona, which holds out until 1982.
During the Carter administration an effort begins to expand coverage under the program to children. While that effort fails, various coverage expansions for children and pregnant women are realized throughout the 1980s.
1981 – Beginning of expansion of managed care in Medicaid. Colorado has had a varied experience with Medicaid managed care and enrollment has waxed and waned over the years. The discussion about managing care in the Medicaid program resurfaced over the last two years as the state initiated the Accountable Care Collaborative project which is designed to coordinate care, in a fee for service environment.
Home and Community Based Services waivers allowed. Colorado was an early adopter of HCBS (1985) and continues to offer significant supports so that people who need long term care can remain in the community.
The Reagan administration proposes to block grant Medicaid. This is the beginning of a battle that resurfaces periodically. The federal government is interested in using block grants to control spending by giving states a fixed allocation of Medicaid dollars, rather than an open ended entitlement to receive matching funds for program expenditures. Some states are interested in the discussion because they want to manage the program free from certain federal requirements. Ultimately block grants may shift significant costs to the states by locking them into a fixed federal dollar allocation, regardless of changes in circumstances, such as increased enrollment during a recession. Block granting also raises concerns about increased state discretion to waive protections that assure that people in Medicaid can access the services they need.
1986 – Medicaid eligible undocumented immigrants are now covered under Medicaid for emergency care (only). Medicaid coverage for immigrants has been a hot button issue for decades. In 1996, Congress required that most immigrants reside lawfully in the U.S. as “Qualified Aliens” for five years before they become eligible to enroll in Medicaid (with exceptions for refugees, asylees and certain others).
1996 – Welfare reform (the Personal Responsibility and Welfare Reform Act) severed any formal link between cash assistance and Medicaid.
1997 – State Children’s Health Insurance Program becomes law. Colorado enacts the Children’s Basic Health Plan, also known as CHP+, in 1998. While Colorado receives a federal dollar for every state dollar spent in the Medicaid program, the state receives a two to one match for CHP+.
1999 – Olmstead Decision by the U.S. Supreme Court requires, in many instances, the provision of community based long-term care services on an equal basis with institutional care.
2000 – Breast and Cervical Cancer Prevention and Treatment Act. Coverage for prevention and treatment becomes a state option with an enhanced federal match. In a hard fought battle, Colorado adopts the program in 2001.
2001 – Health Insurance Flexibility and Accountability (HIFA) waivers created. This was a Bush administration initiative designed to offer states more flexibility in their Medicaid programs. Colorado’s Department of Health Care Policy and Financing brings forward a HIFA proposal in 2005. The proposal goes nowhere because of the potential implications of federal budget neutrality requirements on Medicaid and the state’s General Fund.
2003 – In an attempt to save money during an economic downturn, Colorado temporarily eliminated eligibility for pregnant women in CHP+ and capped enrollment for children. The CHP+ caseload fell dramatically and did not recover until about 2006. Colorado also ends Medicaid eligibility for lawfully present immigrants, even if they have been in the U.S. for more than five years. The move also ended long-term care for lawfully present immigrants, so people in nursing homes and receiving community based long term care services would have lost those services. Many of these immigrants turn out to be Russian Jews; some are holocaust survivors. An injunction related to the adequacy of termination notices stops them from losing eligibility until the General Assembly reinstates coverage in 2005.
2004 – Colorado passes Amendment 35, establishing a tobacco tax. In 2005, the Colorado legislature passes a bill directing a portion of the revenue generated to increase eligibility for pregnant women and children in CHP+, reinstate eligibility for lawfully present immigrants, and eliminate the asset test for children and parents, among other changes.
2005 – Federal Deficit Reduction Act adds new flexibility and authority to increase cost sharing in Medicaid. New proof of identify and citizenship requirements added to the Medicaid program which creates access problems for U.S. citizens in Colorado. A significant number of Medicaid applicants who are U.S. citizens have difficulty today accessing the required documents.
December 2007 – Official start of the Great Recession. Colorado sees growth in Medicaid caseloads that correlate to the economic downturn in subsequent years.
2009 – The Colorado Health Care Affordability Act establishes a hospital provider fee that enables Colorado to draw down new federal matching funds that are used in subsequent years to expand Medicaid and CHP+ coverage for children, pregnant women, and low income parents. Adults without Dependent Children, who make less than about $1,089 a year, and working people with disabilities will become eligible for Medicaid in 2012. No Colorado General Fund is used to support the program.
2009 – American Recovery and Reinvestment Act (ARRA) -provides states with enhanced Medicaid matching funds which helps them through the recession. Colorado’s Medicaid caseload begins to grow as people lose jobs. ARRA prohibits states from reducing Medicaid eligibility. The Children’s Health Insurance Program is reauthorized this year.
2010 – Health reform (Patient Protection and Affordable Care Act, PPACA) passes and creates expansions in the Medicaid program for people up to 133 percent of poverty without the former adherence to categories of eligibility to take effect in 2014. PPACA continues the prohibition on reducing eligibility for Medicaid until 2014 and in CHP+ until 2019.
The timeline is adapted from material compiled by the Kaiser Family Foundation in Medicaid: A Timeline of Key Developments and the Colorado Health Institute in Colorado Medicaid. |
