Lessons from Miss Idaho: Greater Acceptance of (but Not Necessarily Greater Access to) Diabetes Devices

Kate Greenwood Portrait

Cross-Posted at Bill of Health

Given the health law and policy topics that are this blog’s usual fare, some of you may have missed the fact that earlier this month the eighty-eighth annual Miss America pageant was held here in New Jersey, at Boardwalk Hall in Atlantic City. And you may have also missed it (I did) when, this past July, Miss Idaho, Sierra Sandison, a Type 1 diabetic, became a social and traditional media sensation after she competed in the swimsuit competition with her insulin pump clipped to her bikini bottom, visible for all to see. Sandison started a hashtag, #showmeyourpump, inspiring diabetics from around the world to post photos of themselves with their pumps.

Although Sandison was the first contestant to compete in the Miss America pageant with her pump visible, she is not the first contestant with diabetes, or the first to rely on a pump. In 1998, both Deana Herrerra, Miss New York, and Nicole Johnson, Miss Virginia, had the disease, and both relied on pumps to control it. Johnson went on to be crowned Miss America 1999, with a platform of diabetes awareness. Johnson explained to the Philadelphia Inquirer that, before getting the pump, “‘I stuck myself four or five times a day. I was getting scar tissue. I was feeling depressed, and I thought, `I’m never going to have an iota of freedom.’” Since getting the pump, Johnson said, “‘Now, I control the diabetes.”’

Sierra Sandison’s decision to wear her diabetes pump on her hip both contributed to and was the result of a trend toward greater acceptance of medical devices and our need for them. (As Miriam Tucker reported at NPR, “Amputees are increasingly using visible prostheses rather than covering them up. And the ostomy community has its own version of the ‘show me’ campaign.”) Nicole Johnson told Tucker that “‘Our culture seems to be more accepting today, as opposed to when I was diagnosed in 1993.’”

Perhaps unsurprisingly, the increase in acceptance has not translated into easy or uniform access to the medical devices that help diabetics manage their disease, including insulin pumps, insulin pens, and continuous glucose monitors. In its 1998 article about Johnson, the Philadelphia Inquirer reported that while “most health insurers” covered pumps, coverage for the accompanying supplies was less uniform. As a result, “Johnson and other advocates [were] calling for standard, universal [health insurance] coverage of pumps and all diabetic equipment.” Coverage of diabetes equipment and supplies is still an issue today. The American Diabetes Association indicates on its website that ensuring that private and public health insurance “provide access to the services, tools and education necessary to meet the needs of people with diabetes and prediabetes” is one of its top advocacy priorities.  The device company Medtronic writes on its website that, as was the case in 1998, most private insurance companies cover pumps, subject to any applicable deductible or co-insurance (which could be a substantial barrier, given that pumps can cost in excess of $6,000), but coverage by public insurance and, in particular, by Medicaid, is more variable.

Here, I circle back to New Jersey. A report issued earlier this year by the Center for Health Law & Policy Innovation at Harvard Law School indicates that New Jersey Medicaid “cover[s] diabetes equipment and supplies, as well as prescription drugs including metformin and insulin.” There are concerns about the quality of the coverage, though. The report indicates that New Jersey’s Medicaid managed care organizations (MCOs) “tend to frequently switch which brands of glucose meters and test strips they cover, as well as which brands of insulin they include on their drug formularies,” which causes patients to become confused. The providers that the Center for Health Law & Policy Innovation interviewed “described patients coming to primary care appointments with grocery bags filled with glucose monitors and test strips, completely unsure which strips go with which monitor and functionally left without any testing supplies as a result.” The report also flags as an issue monthly limits on test strips that are not grounded in medical necessity.

And that’s not all. Earlier this year, at the Center for Health Law & Policy Innovation’s blog, Alexandra Maron wrote the following:

As an attendee at the New Jersey Diabetes Leadership Forum, I had the pleasure of witnessing a real, live insulin demonstration. Fran Grabowski, Lead Diabetes Educator for the Camden Citywide Diabetes Collaborative and Program Manager at Cooper Diabetes Center, went around from table to table at the Forum throughout the day showing attendees the various tools available for those with diabetes to take their insulin. . . . Ms. Grabowski first demonstrated how to use a syringe to give insulin, and while she noted that the needle is much smaller than it was in the past, it is still uncomfortable for those with diabetes who have to give themselves insulin at least 4 times per day. Ms. Grabowski then showed attendees the insulin pen, which has a remarkably smaller needle than a syringe, but unfortunately is no longer covered under New Jersey Medicaid. She pointed out that this is very unfortunate for those with diabetes in New Jersey because they are forced to use methods that are more time consuming and more painful. She also described the mechanism of insulin delivery systems, such as pumps and patches, which are even easier ways for those with diabetes to receive insulin; however, Medicaid also does not cover those systems.

My initial response to reading Maron’s post was a visceral one. It feels wrong that our wealthy state forces individuals with diabetes who receive Medicaid to take care of themselves using methods that are painful, time consuming, and, for many, less effective. Beyond my gut feeling, it may also be penny-wise but pound-foolish. As the Center for Health Law & Policy Innovation concludes in its report:

“The limits on access to diabetes supplies and services mean that fewer patients are using these services. This is probably causing a number of unnecessary deaths and significant morbidity in the state, given that sustained reductions in A1C [a measure of average blood glucose level over the previous three months] are associated with a 21% lower risk of death. It is also probably costing New Jersey millions of dollars.”


Medicaid Expansion Under the ACA Just Makes Sense

Adam Mitchell

By Adam Mitchell

I am not a proponent of big government or social welfare programs. I did not vote for Obama or support the Affordable Care Act. However, after researching the current Medicaid expansion debate, I am having a hard time supporting the “opt out” point of view. Ultimately, opting out of Medicaid expansion is only going to further disadvantage the poor and keep them from receiving early and preventative care.

Originally the ACA called for a mandatory state Medicaid expansion. If a state refused to expand Medicaid, the federal government could withhold all federal Medicaid funding until the state complied. However, in NFIB v. Sebelius, the Supreme Court struck down this “gun to the head” provision when it held that the federal government could not rescind existing Medicaid funding as a consequence for a state’s failure to expand Medicaid.

In short, Sebelius gave states the choice to opt in or to opt out of the ACA’s Medicaid expansion.  As of June 10, 2014, as shown in this Kaiser Family Foundation graphic, 26 states plus Washington, D.C. have opted in and expanded Medicaid, leaving 3 states considering expansion, and 21 not expanding at the current time:


The states opting out of the expansion have left many uninsured who would otherwise have qualified for Medicaid under the ACA. These “opt out” states cite future costs of expansion as their main objection. They argue that even though the federal government will cover 100% of the expansion costs up front and gradually step it down to 90% by 2022 ,  that even the 10% left to the states will not be financially sustainable. The opt-out states also argue that the government is unreliable and may not be able to fulfill its financial commitment in the future, leaving the states with the bill for the expanded coverage. For example, Florida Gov. Rick Scott has used this argument to defend his decision not to expand Medicaid in Florida. (Scott, of course, subsequently came to favor expansion.)

However, these arguments ignore the reality that medical bills for the uninsured are already being paid by the state and the taxpayer. The counter to the arguments of Rick Scott and other opt-out proponents follow a more logical form of thinking. The uninsured do not receive preventative care or regular check-ups. Furthermore, any ailment is not of concern until it reaches a point where it becomes an emergency room-worthy condition. The uninsured also utilize emergency room services in lieu of a primary care provider. Therefore, insuring these individuals so that they may be treated before they develop an emergency room worthy-condition would be the logical step in reducing health care related costs, not increasing them. This Kaiser Commission on Medicaid and the Uninsured graph analyzing 2011 NHIS data illustrates this point:


On the whole, those with health insurance (private or Medicaid) v.s. the uninsured are significantly more likely to have a usual source of care and significantly less likely to postpone or forgo care due to cost. This equates to the insured seeking and receiving early and preventative care which is far more effective and less expensive than ignoring the problem until emergency care becomes a necessity simply because you are uninsured. Insurance also allows individuals to seek medical care from a primary care provider rather than utilizing emergency room services for conditions that are not emergencies. The old adage, an ounce of prevention is worth a pound of cure, appropriately summarizes this position.

Furthermore, even if opt-out states refuse to change their position, their Medicaid enrollment is likely to grow nonetheless because of other ACA provisions. For example, as a result of the individual mandate, many signing up for health care on a state exchange will find that they are eligible and sign up for Medicaid. Also, Medicaid enrollment will climb due to an increase in part-time positions as a result of employers not wanting to offer health care to full-time workers as required under the ACA. Therefore Medicaid is going to grow from pre-ACA levels regardless of whether states opt in or out. How much it grows and the amount of federal funding for said growth remains the decision of the individual states but currently the smart move is to expand Medicaid.

Adam Mitchell is a Juris Doctorate student at Seton Hall University School of Law. We are very pleased to welcome him to the blog today.


Ensuring Successful Reform Follow-Through, Part 2: Affordability

jacobi-176x220_1Cross-Posted at HealthLawProf Blog

Health reform is an ongoing project.  In my last post, I noted that the success of ACA enrollment frees up some bandwidth to grapple with other outstanding implementation tasks – tasks that are vital to supporting the goals of the Affordable Care Act.  I tried to focus on issues with a short- or medium-term horizon, and which could be tackled largely by state or private-sector actors – that is, without change in federal law.  In this post, I’ll talk about affordability (the first “A” in the ACA).  First, the good; then, the problems; finally, some potential solutions.

 The good

 Almost five million new Medicaid enrollees, of course, have affordable care.  There are indications that Medicaid expansion will gradually come, in some form, in many red states, including Indiana, which is proposing what sounds like a mash-up of the Basic Health Plan and an 1115 waiver.  Beyond Medicaid, several affordability provisions support access in private insurance:

 Modified community rating, with 3:1 ratio limit.

  • Abolition of most annual/lifetime limits on coverage.
  • Annual out-of-pocket limit of $6,350/individual and $12,700/family (2014).
  • Actuarial value requirements for QHPs.
  • No cost-sharing for preventive care.

Low-income purchasers on the exchanges have additional protections:

  • Premium support, limiting the effective cost of coverage for people at or below 400% of FPL to 2% to 9.5% of income.
  • Further reductions in out-of-pocket caps by two-thirds for those at or below 200% of FPL, by one-half for those at or below 300% of FPL, and by one-third for those at or below 400% of FPL.
  • Reductions in cost sharing (point-of-care copayments and deductibles) for those below 250% of FPL, raising the actuarial value of their coverage to as high as 94%.

The bad

This protection is real and substantial – a tremendous improvement from the pre-ACA days when, as chronicled by Melissa Jacoby, Teresa Sullivan, Elizabeth Warren and others,  medical debt played a large part in personal bankruptcy filings, and, significantly, the majority of those filing with medical debt were insured.

The limits on cost-sharing directly address many of these concerns, but problems remain for the lowest-income folks.  The actuarial value standards provide very useful touchstones for evaluating the richness of coverage, and further supports for low-income persons help.  For example, a person at 180% of the FPL ($21,006 per year) is eligible for much very rich coverage with a 87% actuarial value.  But this measure is an average, and a chronically ill person could be faced with higher – perhaps much higher – out of pocket costs than the average person.

The backstop for that problem is the out-of-pocket cap.  The ACA shrinks the out of pocket limit for our guy making $21,006 per year by two-thirds, to about $2395. But is his care now affordable?  Maybe not.  Plans can mix and match their patient cost-sharing as between the copayments and deductibles that go into the patient share.  So, while on average an individual making $21,006 per year will pay only 13 cents per dollar of service provided, in any individual case his out-of-pocket costs might practically bar him from service.  Michelle Andrews explained this last year in Kaiser Health News:

Insurers have some flexibility in how they structure their plans to meet cost-sharing reductions. But in states that will require plans to standardize deductibles, copayments and coinsurance amounts, it’s possible to see how out-of-pocket costs may vary.

In California, for example, a standard silver plan will have a $2,000 deductible, a $6,400 maximum out-of-pocket limit and a $45 copayment for a primary care office visit. Someone whose income is between 150 and 200 of the poverty level, on the other hand, will have a silver plan with a $500 deductible, a $2,250 maximum out-of-pocket limit and $15 copays for primary care doctor visits.

That $500 deductible could loom large when the rent bill is coming due.  And in many states, there is far less uniformity and transparency, allowing for even greater barriers.

Potential solutions

It is clear that the ACA solves a raft of affordability problems.  But, problems remain for those over-income for Medicaid and hard-pressed, notwithstanding subsidy, to meet the costs of care.   The ACA’s goal is to connect folks to care, and the “near poor” are still in a precarious position.  What can be done short of unlikely improvements in federal law?

First, and most obviously, states and advocates should be examining the Basic Plan Program, which will finally be ready for roll-out  in 2015.  The Program, authorized by § 1331 of the ACA, is a public health insurance program intended to bridge the gap between Medicaid and subsidized private insurance for people with income between 138% and 200% of FPL.  It could serve two purposes:  It could reduce “churn” between Medicaid and private insurance as insureds’ income fluctuates in the low range, therefore minimizing disruption in ongoing access to providers.  It could also improve the affordability of coverage by allowing states to piggy-back on their Medicaid provider networks and premium structure, allowing Program participants rich coverage with little or no out-of-pocket cost.  There are downsides: the Program would reduce the exchange’s pool, perhaps increasing per-enrollee costs and threatening actuarial destabilization of the individual plan market; and Medicaid provider networks are already fragile in many states.  But faced with the risk of cost-based attrition and/or low service utilization by low-income exchange enrollees, states will want to consider this option.

Second, states could create “wrap-around” support for low-income exchange enrollees without adopting the Basic Health Program.  As Heather Howard and Chad Shearer have described, states can use their own funds to fill the gap left for the very poorest individual exchange enrollees.  Wrap-around programs flow from the experience of states that had, prior to the adoption of the ACA, used Medicaid waivers to expand affordability supports beyond the reach of traditional Medicaid.  It is likely true, as Howard and Shearer note, that “[g]iven general state resource constraints, . . . the use of state-only dollars is unlikely in all but a few unique circumstances.”  The confluence of two factors might allow advocates to prevail on states to (re)consider such supplemental programs: most state economies are on the upswing, and we will soon have experience on the extent to which continuing affordability problems are causing very low-income exchange insureds to either drop coverage or forego medically necessary care.  Where data are available and states are willing to take a long-range view to the importance of maintaining as many as possible in meaningful coverage, the expense of a wrap-around program might represent state money well spent.


Medicaid ACOs in New Jersey: At the Starting Line at Last

Kate Greenwood_high res 2011 comp

Cross-Posted at Bill of Health

Nearly three years ago, in July of 2011, Tara Adams Ragone wrote a blog post for Seton Hall Law’s Health Reform Watch blog entitled “Community Based Medicaid ACOs in New Jersey: A Signature Away”. As Professor Ragone explained, a month earlier the New Jersey legislature had passed Senate Bill 2443, which established a Medicaid accountable care organization (ACO) demonstration project, but Governor Chris Christie had not yet signed it. “It’s an exciting time for growth and innovation in the Garden State,” Professor Ragone wrote, “if we just get that signature.”

Governor Christie did go on to sign Senate Bill 2443 into law, in August of 2011, but the implementation process has been protracted. The act required the Department of Human Services to “adopt rules and regulations” that provided for oversight of the quality of care delivered to Medicaid recipients in the ACOs’ designated geographic areas and set standards for the gainsharing plans that participating ACOs must develop. The deadline for adopting the regulations was in June of 2012, but they were first issued, in draft form, in May of 2013. The final regulations were not adopted until earlier this week, one day before the proposed regulations were due to expire.

As Andrew Kitchenman reports here, with the regulations in place, the three community-based organizations that have been preparing to launch Medicaid ACOs, one in Camden, one in Trenton, and one in Newark, can finally get started. Unlike the State, they will have to move quickly; the deadline for applying to participate in the three-year demonstration is July 7th.

There is, in Kitchenman’s words, “a final piece to the puzzle”—the participation of managed care organizations (MCOs). In 2011, when New Jersey’s Medicaid ACO statute was passed, many of the State’s Medicaid beneficiaries were covered on a fee-for-service basis. The expectation was that ACOs’ efforts to coordinate care and reduce waste would be rewarded with a share of any resulting savings to the State. In 2014, however, the landscape has changed.  Nearly all of New Jersey’s Medicaid beneficiaries are now enrolled in Medicaid MCOs, and it is uncertain whether Medicaid MCOs will be willing to enter into shared savings arrangements with Medicaid ACOs.

Recently-released data from the second year of operations of Colorado’s Accountable Care Collaborative Program suggest that, if New Jersey’s MCOs can be persuaded, incentivized, or required to work with its nascent ACOs, there are both cost savings and quality gains to be had. Colorado has not yet enrolled individuals with disabilities or those who are dually eligible for Medicaid and Medicare in its Program, but the Program nonetheless achieved gross savings of $30 per member per month in its second year, adding up to $44 million. The State’s net savings were $6 million, after paying the Program’s regional ACOs and participating primary care providers for care coordination and other services, as well as a contractor charged with providing “actionable data at both the population level and the client level”.

The quality gains Colorado achieved in the Program’s second year were substantial, including a 20% reduction in hospital readmissions, a 22% reduction in hospital admissions among members with chronic obstructive pulmonary disease, and “[l]ower rates of exacerbated chronic health conditions such as hypertension (5%) and diabetes (9%)[.]” Emergency room utilization, on the other hand, increased, albeit at a slower rate than for Medicaid enrollees not participating in the Program.

As Diana Rodin and Sharon Silow-Carroll explained in a March 2013 report on Colorado’s approach to Medicaid accountable care, the State wanted to move away from fee-for-service but did not want to return to traditional capitated managed care, which had led to “nearly all Medicaid managed care plans [leaving] the state as a result of conflict over rates.” Colorado currently makes a portion of the payments it makes to the regional ACOs and to participating providers contingent on the achievement of certain quality improvements. Eventually, the State intends “to increase the portion of the monthly fee that is at risk, as well to pilot payment reforms that test alternatives to the fee-for-service component.”

It will be interesting to see if Colorado succeeds at moving away from fee-for-service without returning to traditional capitated managed care, and if New Jersey succeeds at moving towards accountable care within a managed care environment.


Commonwealth Study Finds Access to Health Care for Low-Income Populations Varies by State

September 26, 2013 by · Leave a Comment
Filed under: Disparities, Health Reform, Medicaid 

Doctor's OfficeThe Commonwealth Fund (“Commonwealth”) has recently released its first-ever Scorecard, which provides a state-by-state comparison of the health care experiences of the 39 percent of Americans with incomes less than 200 percent of the federal poverty level. The report, titled Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations, finds striking disparities by income within and among states, and many news sources have quickly made these findings known to the public.

The purpose of the study was to identify opportunities for states to improve how their health systems serve their low-income populations and to provide benchmarks of achievement tied to the top-performing states. The report is based on thirty indicators of access, prevention and quality, potentially avoidable hospital use, and health outcomes, but does not analyze the potential effect of the 2010 healthcare law, the Patient Protection and Affordable Care Act (“ACA”). This law was designed, in part, to guarantee healthcare access for all Americans no matter where they live and the study’s lead author and Commonwealth’s senior vice president Cathy Schoen has suggested that “[w]e ought to be able to close the geographic divide … There is potential for a real leap forward.”

More specifically, the study finds that the poor in the highest-ranking states are more likely to be covered by health insurance, to have a regular source of medical care, and to get recommended preventative care. Health system performance for low-income populations in leading states is often better than the national average and better than it is for high-income populations in other states. Several news articles have pointed out that Texas is the state with the largest rate—55 percent—of uninsured low-income adults. Nine of the ten states at the bottom were in the South–other states at the bottom include Alaska, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Virginia and Wyoming, all of which have refused to expand their Medicaid programs. New Jersey is ranked number 26. It is also among the states that will participate in the Affordable Care Act’s Medicaid expansion.

Significantly, Commonwealth notes that having low income does not have to mean below-average access, quality, or health outcomes. Further, the Scorecard finds much less state-to-state variation in health and health care experiences among people with higher incomes.

As the ACA continues to take effect, the report is optimistic that the Act “represents a historic opportunity for states to provide better health care to economically vulnerable people by providing resources to overcome the geographic and income divide—especially for states with high rates of poverty.” In light of the Senate’s recent 100-0 vote to avert government shutdown, the date on which health care exchanges set up under the Affordable Care Act will go into effect, October 1, looms ahead.

Photo, of a doctor’s office in New Orleans, courtesy of Bart Everson.


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