Feds changing rules to encourage Medicaid expansion in the states
Feds changing rules to encourage Medicaid expansion in the states
The U.S. Department of Health and Human Services (HHS) wants more low-income people to be eligible for Medicaid and is proposing new rules to give states greater flexibility in determining Medicaid eligibility. And newly reported research demonstrates the need for broader insurance coverage for adults.
Government analysts say the rule changes potentially could help tens of thousands of people — particularly the elderly, people on disabilities, and families with disabled children — to obtain Medicaid coverage while living at home, rather than being forced into nursing care facilities as a condition for coverage.
The department says the proposed changes "address problems created by existing rules that limit Medicaid eligibility for certain individuals to outdated, extremely low-income levels that were used in the old Aid to Families with Dependent Children program," before welfare reform eliminated that program.
The changes are intended to help families with incomes slightly above traditional Medicaid limits but with very large medical bills.
Under current "medically needy" rules, a state can offer Medicaid coverage to such people once they have spent so much of their income on medical bills that what is left meets the state’s medically needy income standard.
In more than 40% of the states, however, HHS says that standard is significantly below the poverty level. Under the federal proposal, states could disregard portions of someone’s income, such as the income necessary to pay for food, clothing, or housing.
"This proposal has important potential to open doors to community living for thousands of Americans who are able to live at home and do not want to be confined in nursing homes," says Health and Human Services Secretary Donna Shalala. "It can enable people to obtain the services they need to live in their own homes despite a chronic illness or disability and lead fuller lives of their own choosing."
The proposed rule is of special significance for the elderly and people with disabilities. Under current rules, people in institutions can qualify for Medicaid coverage at much higher income levels than if they lived in the community.
The department says such an "institutional bias" is a barrier to living in the community for many elderly people with disabilities. The proposed change would give states the flexibility to change their own rules so that the elderly or people with a disability would not have to lose health coverage if they move into a community setting.
States also could use the new rule to help low-income people with disabilities to participate in the work force. For example, a state might disregard income from a savings account used by a worker to save funds for the purchase of a home, automobile, or similar item that promotes independence.
The proposed regulation also could allow states to provide coverage to additional families and children who cannot be covered under existing rules. For example, states would have the flexibility to offer health insurance coverage under Medicaid to young adults ages 19 and 20 who are still in school or are just beginning employment.
"This change could permit the elderly and others to retain enough income to meet life’s basic living expenses and still get help with their catastrophic medical bills," says Mike Hash, acting administrator for the Health Care Financing Administration.
New federal spending required by the proposed regulation is estimated at $960 million over five years. States would be required to spend a similar amount during that period.
Meanwhile, support for attempts to broaden coverage for adults, particularly those with chronic health conditions, comes from a study reported in the Oct. 25 Journal of the American Medical Association.
In that study, researchers found that many uninsured adults are not getting the medical care they need, despite a growing perception in the country at large that such care is available from physicians and hospitals. In examining survey data for more than 220,000 adults, the researchers reported that 14% of respondents lacked health insurance and 10% had been without insurance for a full year.
Nearly 70% of those who described themselves as being in poor health and 50% of those who said they were in fair health reported that they could not see a physician when they needed to in the past year because of cost.
"Many uninsured adults are going without proper medical attention," says John Ayanian, MD, associate professor of medicine and health care policy at Harvard Medical School and the study’s lead author. "Thirty-two percent of women without health insurance for [more than] a year report not getting a mammogram in the past two years. Twenty-six percent of the long-term uninsured with hypertension or diabetes say they haven’t had a checkup with a doctor in two years. From a public health perspective, these numbers are a great concern."
The proportion of uninsured individuals was higher among younger adults, men, blacks, Hispanics, residents of the South and West, those with less education and lower incomes, and those who were self-employed, unemployed, or not in the labor force. Nearly two-fifths of long-term uninsured adults and one-third of the short-term uninsured adults reported they could not see a physician in the past year when needed due to cost. In addition, in all clinical risk groups studied, long-term uninsured adults were significantly more likely than insured adults to have lacked a routine checkup.
Long-term uninsured adults also were significantly more likely than insured adults to have unmet needs for many preventive services, including mammography, Pap tests, sigmoidoscopy, and hypertension screens. The only services that were received at a rate similar to that of the insured population were glycosylated hemoglobin measurements and pneumococcal vaccinations among adults with diabetes and HIV screening among those with self-perceived risk. Long-term uninsured adults were three to four times more likely not to have received clinical services such as breast cancer and hypertension screening.
The researchers say that "although patchwork programs can fill gaps in specific services such as cancer screening for uninsured adults, national health goals represented in the Healthy People 2010 objectives are unlikely to be met without more vigorous efforts to extend affordable health insurance to the uninsured for a wide range of basic medical services. Our findings suggest that the health benefits of extending insurance to these groups could be substantial, but the costs borne by uninsured people must be low enough to encourage broad participation, especially for those who are poor or near poor."
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