Health Law and Policy Update
Headlines of the week
Hickenlooper announces key department directors
Gov.-elect John Hickenlooper on Tuesday announced the appointment of a child welfare specialist from Wisconsin to head the Colorado Department of Human Services. The appointment is important to health policy because the integration of human services and health care services is important to providing adequate support for low-income families. The appointee, Reggie Bicha, was mostly recently Secretary of the Department of Children and Families for the state of Wisconsin, the Hickenlooper transition team said in a news release.
On Wednesday, Hickenlooper announced the appointment of Dr. Chris Urbina as executive director of the Colorado Department of Public Health and Environment. That department is also important to health policy because it oversees activities such as the nursing home visitor program, investigation and prevention of infectious diseases, and early-intervention and prevention strategies. Urbina is now the Director of Denver Public Health at Denver Health. In his new role, he'll also be the state's chief medical officer.
Examining Bill Ritter's health care legacy
Gov. Bill Ritter made a commitment to improving health care access, delivery and coverage during his campaign. In his inaugural address four years ago, Ritter promised a better future for Colorado, said he would end the crisis of the uninsured and enact comprehensive health care reform.
In the view of the Colorado Center on Law and Policy, Ritter made significant progress toward those goals. He leaves Colorado well positioned for health care reform if the state can figure out how to efficiently enroll people in public-assistance programs such as Medicaid and ensure the state has a functional technology infrastructure, which is needed to create a successful health insurance exchange.
Ritter inherited a work in progress. When he took office, the Blue Ribbon Commission on Health Care Reform, a legislatively established body, had been meeting for a number of months. The governor integrated the work of the commission into his vision for the state, added his appointees to the group and made a number of the commission's recommendations cornerstones of his health initiatives or "Building Blocks for Health Reform."
Some highlights of his Building Blocks
Coverage expansions
The most significant health insurance coverage expansion to be realized in a generation in Colorado is currently in progress. As a result, by 2012 an estimated 130,000 uninsured children, low-income parents and single adults, and working people with disabilities will be made newly eligible for Medicaid and Child Health Plan Plus (CHP+). That coverage expansion was funded through a hospital provider fee established by the Colorado Health Care Affordability Act (HB09-1293). The act assesses a fee on hospitals, uses those fees to draw down matching federal funds and then returns the initial investment to hospitals.
In a time of significant budget challenges for the state, it is remarkable that Colorado has been able to do so much to reduce the number of uninsured. In addition to funding coverage expansions, the provider fee raises reimbursement rates for hospitals that see indigent patients thought the Colorado Indigent Care Program. In time, that increase in rates will make it easier for people without insurance to access care as well as begin to address the problem of cost shifting, where hospitals recoup the expense of caring for the uninsured by increasing rates for those with insurance.
Outreach and enrollment
The Department of Health Care Policy and Financing made outreach and enrollment of children and families in Medicaid and CHP+ a priority. In a significant shift from the previous administration, Ritter concentrated on reducing barriers to access to public health insurance programs. Under his administration, provider rates for pediatricians increased, and Colorado committed to provide a Medical Home for every child. Today, at least 236,000 children enrolled in Medicaid and CHP+ have a Medical Home. In addition, children were made presumptively eligible for Medicaid and CHP+, and Colorado will remove the five-year bar to eligibility for Medicaid and CHP+ for lawfully present immigrant children as soon as funds are available.
Insurance reform
Ritter appointed Insurance Commissioner Marcy Morrison, who was a stanch ally to consumers. In 2010, Morrison received the Excellence in Consumer Advocacy award from consumer representatives at the National Association of Insurance Commissioners (NAIC). She was recognized for supporting insurance consumers in Colorado as well as at NAIC. She strengthened the Colorado Consumer Insurance Council by helping to make it a statutory advisory body. In 2008, Morrison reached an agreement with Kaiser Permanente in the amount of $160 million as a result of an investigation launched by the Division of Insurance into excess reserves held by the company. Kaiser ultimately refunded a total of $77.5 million dollars a year for two years through premium credits to individuals and employers and expanded its Medical Financial Assistance Program by $5 million over two years. In 2010, after launching an investigation as a result of numerous consumer complaints about extraordinary rate increases by Rocky Mountain Hospital and Medical Service, Inc. (Anthem), Morrison reached an agreement with Anthem in which 90,000 individuals insured by Anthem between January and September 2010 shared a $20 million premium credit.
Ritter stood up for consumers when he signed HB07-1355. The Colorado legislature has gone back and forth since 1994 on whether insurance companies should be permitted to charge small businesses (two to 50 employees) more if they have employees with health conditions. HB07-1355 prohibited basing small business insurance rates on the health status of employees. That was a substantial win for consumers and businesses. Increasing rates based on health status is one of the surest methods of driving businesses the insurance industry does not want to serve out of coverage.
Some other insurance measures and reforms passed in the past four years include:
- Standardization of health plan ID cards and requiring the use of magnetic strips on all cards. (SB08-135)
- Providing the Division of Insurance the authority to review insurance premium rate increases and reject them if they are unreasonable. (HB08-1389)
- Giving the Division of Insurance the authority to seek restitution for consumers wronged by insurance companies and producers (HB08-1228)
- Requiring insurers to use a standard application in the individual insurance market simplifying the application process for consumers. (HB10-1242)
- Requiring insurance policies to be written in plain language (HB10-1166)
- Beginning the process of simplifying claims submission by doctor's offices by standardizing insurance coding (HB10-1332)
- Standardizing policy forms and clarifying the explanation of benefits (HB10-1004)
- Banning gender rating individual health insurance (HB10-1008)
Addressing workforce issues
Strengthening loan forgiveness programs and providing incentives for health care professionals to practice in rural and underserved communities.
Cost containment and delivery system reform
In 2008, Ritter issued an executive order that established the Center for Improving Value in Health Care (a 208 Commission recommendation). CIVHC will look at long term strategies for ensuring better value for the $30 billion spent annually in Colorado on health care and work to "contain costs, improve quality and expand the availability of care." CIVHC is in the process of becoming an independent nonprofit and just received a $5 million grant from the Colorado Health Foundation. It is likely to be an enduring legacy of the Ritter administration.
The All Payer Claims database (HB10-1330) requires analysis of claims information from all payers (public and private). The information will provide significantly better comparative information about costs than is available today. It will be invaluable as Colorado develops strategies to improve health care quality and control costs. CIVHC is charged with implementation of the database.
Kids
CHP+ now offers enhanced mental health services on par with Medicaid benefits. In addition, the administration partnered with the Colorado Health Foundation and Kaiser Permanente to launch LiveWell Colorado, an organization dedicated to combating childhood obesity.
Access
Presumptive eligibility for Long Term Care was established during the Ritter administration.
Technology
Ritter's administration oversaw investments in health information technology and strengthening of public health programs.
Some disappointments
CBMS
There continue to be substantial delays in processing applications for Medicaid, CHP+ and other public benefits in Colorado. Far too many people go hungry and without critical medical care as a result. This is a problem Ritter inherited, and it's attributable in part to the failed launch in 2004 of the Colorado Benefits Management System (CBMS). The Ritter administration ought to have invested the time, energy and resources into getting people benefits within the required schedule. Despite many significant improvements designed to ease enrollment in public health insurance programs, Colorado still performs very poorly when it comes to timely processing of new applications and application renewals for public medical programs. The problems represent a significant barrier to access; it's way past time to fix them.
Targeting of immigrants
Lawfully present immigrants continue to be on the front line for cuts during budget crises. During the past two years there have been substantial cuts to eligibility for medical care for Old Age Pensioners. Old Age Pensioners are all older than 60 and many are in frail condition. They are not eligible for Medicare, and during the past two years through initiatives launched by the Department of Human Services many legal immigrant Old Age Pensioners have lost their pensions as well as access to the Old Age Pension Medical Care Program.
Insurance reform
The governor signed two bills, HB09-1012 and HB10-1160, both ostensibly about promoting wellness. Each furthers an insurance company agenda in a longstanding battle about whether carriers ought to be permitted to charge people who are less desirable insurance risks more or otherwise create obstacles that impede their ability to take advantage of their health insurance coverage.
Ritter's health reform legacy
Ritter and his staff have made substantial effort to begin implementation of the Affordable Care Act (ACA) including:
- Drawing down federal dollars ($1 million) to enhance the rate review capacity of the Division of Insurance
- Establishing one of the most successful high risk pools in the nation, GettingUSCovered
- Drawing down a $1 million planning grant to design Colorado's Health Insurance Exchange
- Securing funding for a Money Follows the Person Initiative
- Securing funding to enhance nurse home visitation programs
- Holding 11 public meetings statewide on health insurance exchange design
With very able staff in Health Reform Implementation Director Lorez Meinhold and current HCPF Director Joan Henneberry, who will soon leave that position to oversee the Health Exchange Planning Grant, Colorado is well positioned to move forward with health reform.
Advancing the debate
11 reasons not to repeal health reform in 2011 (or ever)
U.S. House Republicans have vowed to hold a vote on Wednesday to repeal the Affordable Care Act. While the vote would not likely make it past the House, it is worth considering all of the new benefits of health reform that would disappear if repeal were successful. The Affordable Care Act is an enormous step in the right direction, recognizing the need to create access to coverage for the uninsured and the underinsured, and making insurance work better for those who have it by giving consumers greater control and making insurance companies more accountable. That is just the beginning, because health reform also provides the catalyst and the means to get the nation moving toward payment and delivery system reforms that will contain costs, increasing the health care workforce and focusing on prevention and public health.
In the spirit of new year's list making, the list below describes 11 important reasons Congress should not repeal health reform. These are the policy reasons, but there are millions more practical reasons: 50 million uninsured Americans.
1. After repeal, no law would require insurance companies to offer coverage to adult children up to age 26 on a parents' health plan. An estimated 53,926 uninsured young adults in Colorado were eligible to receive coverage on their parents' plans.
2. Tens of thousands of small businesses in Colorado would no longer be eligible to receive tax credits for providing health coverage to their employees.
3. Forty Colorado employers would lose the financial relief they received under the Early Retiree Reinsurance Program that helps them continue to provide health coverage to their retirees ages 55 to 64.
4. The 471-plus people in the new pre-existing condition insurance plan, GettingUsCovered, would lose coverage.
5. Insurance companies would once again be able to refuse insurance to children with pre-existing conditions.
6. Insurance companies would once again be able to cancel insurance policies for sick people.
7. Prescription drugs would be less affordable to the 31,675 seniors who hit the coverage gap (the "donut hole") in their Medicare prescription drug benefits. Those seniors received $250 rebate checks in 2010. Those same seniors who hit the coverage gap in their Medicare prescription drug coverage would lose access to the 50 percent discount on brand name drugs in 2011. And qualifying seniors would not receive free wellness checks or preventive care services beginning in 2011.
8. New insurance plans would no longer be required to provide free preventive services.
9. Insurance companies could bring back annual limits on coverage.
10. Grants of more than $50 million in Colorado would be canceled, removing support for increased capacity in health centers, expanded primary care residency programs, enhanced public health initiatives, increased oversight of unreasonable insurance rate increases and enhanced biomedical research.
11. Insurance companies would no longer be required to maximize their customers' dollars under regulations requiring a minimum share of premium revenues be spent on health care and quality improvement.
Some context for the debate over end-of-life planning
New Medicare regulations that included language about advance directives and end-of-life planning have revived the furor over so-called "death panels" that diverted so much attention from the substance of national health reform during the debate over its passage. This week, facing a threatened vote by the U.S. House of Representatives on repeal of the Affordable Care Act (ACA), the Obama administration pulled back the advance directive language in the new regulations.
The practical issue is whether doctors get paid for time spent counseling patients on end-of-life decisions. Many people don't realize doctors typically don't get paid for time spent with patients unless there is a billing code for the particular treatment or procedure the doctor provides. The regulation was designed to pay doctors so they can afford to spend time with patients who want advice as they and their families think about and plan for the end of life.
Before passage of the ACA, seniors were eligible for a one-time "Welcome to Medicare" visit with their doctor. Health reform eliminated copayment requirements of up to 20 percent for the "Welcome to Medicare" visit and added new annual wellness visits (with no copayments) to the doctor.
Since 2008, the "Welcome to Medicare" visit has covered voluntary counseling on end of life planning. In December 2010, Medicare issued rules outlining what would be covered in the new annual visits provided for by the ACA. Among the services covered was voluntary counseling on advance directives and end-of-life planning. That was seen as an extension of what was already available in the one time "Welcome to Medicare" visit.
"Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives," the administration said in the preamble to the Medicare regulation, quoting research published this year in the British Medical Journal. The administration also cited research by Dr. Stacy M. Fischer, an assistant professor at the University of Colorado School of Medicine, who found that "end-of-life discussions between doctor and patient help ensure that one gets the care one wants." In that sense, Fischer said, such consultations "protect patient autonomy."
As more and more doctors, particularly primary care doctors, limit the amount of time they spend with patients, it seems likely many seniors will not get the benefit of time with a doctor to think ahead about the care and treatment they want as they reach the end of life. The New York Times offers some useful background and a report on this week's developments.
What you can do
Urge representatives to oppose repeal
On Tuesday and Wednesday, call your House member and Senators Udall and Bennett to let them know you support health reform. Ask House members to vote against repeal. FamiliesUSA is sponsoring a toll-free number to the Capitol switchboard: (866) 922-4970.
Health Law and Policy Update is issued weekly by the health staff of the Colorado Center on Law and Policy. Subscribe by e-mail or read previous editions.
Health Care Director
Elisabeth Arenales
Health Care Attorney
Adela Flores-Brennan
Special Counsel
Ed Kahn
Communications Director
Perry Swanson
Released Jan. 7, 2011