Medicaid Shift Fuels Rush for Profitable Clients
When Hurricane Sandy flooded two adult homes in Queens, hundreds of disabled, elderly or mentally ill residents were caught in the surge. After weeks in public shelters, they were bused, over their objections, to a dilapidated four-story building called King’s Hotel, in a crime-ridden section of Brooklyn.
Many had not showered in days. Crammed three cots to a room, they lacked basics like clean underwear. But in the parallel universe of New York’s redesignedMedicaid program, they represented a gold mine.
Business managers from CenterLight Healthcare, a managed care company specializing in long-term services, huddled in a ground floor hotel room, poring over health data and spreadsheets that identified residents by name and room number. At the managers’ direction, crews of enrollment nurses tracked down residents to pressure as many as possible to sign up with the company’s long-term care plan, according to current and former CenterLight employees who were there.
To CenterLight, which had struck an unusual deal with the state to run the hotel as a temporary adult home, the evacuees were a captive audience, and each signature was worth $45,600 a year in fixed monthly Medicaid fees. To an agency supplying aides there, the signatures also meant more money.
But for taxpayers, the sign-up frenzy at King’s Hotel points to hidden costs and potential abuses in an ambitious Medicaid overhaul in New York that has shifted $6 billion in public spending on long-term services for disabled and aged people to managed care companies like CenterLight. The state’s goal was savings, but the changes set off a scramble among managed care companies and service providers to enroll clients requiring minimal care, including residents of adult homes who could be brokered in bulk, an investigation by The New York Times found. Many frail people with greater needs were dropped, and providers jockeying for business bought, sold or steered cases according to the new system’s calculus: the more enrollees, and the less spent on services, the more money the companies can keep.
Adult home residents, like those caught in the hotel, had long been victimized under the old fee-for-service Medicaid system, in which providers were paid for services rendered. Now, under managed care, they find themselves prey to new versions of old tactics, including intimidation to accept services they do not need.
Insurers Say Most Who Signed Up Under Health Law Have Paid Up
By ROBERT PEAR
WASHINGTON — Most of the people choosing health plans under the Affordable Care Act — about 80 percent — are paying their initial premiums as required for coverage to take effect, several large insurers said Tuesday on the eve of a House hearing about the law.
But the health insurance industry said the total of eight million people who signed up included “many duplicate enrollments” for consumers who tried to enroll more than once because of problems on the website.
“Insurers have many duplicate enrollments in their system for which they never received any payment,” said Mark Pratt, a senior vice president of America’s Health Insurance Plans, an industry trade group.
“It may be a matter of months,” Mr. Pratt added, “before insurers know how many people activated their coverage by paying their share of premiums.”
President Obama said last month that eight million people had signed up for health insurance under the Affordable Care Act, surpassing the administration’s original goal of seven million in the federal and state insurance exchanges.
In testimony prepared for a hearing of a panel of the House Energy and Commerce Committee on Wednesday, Mr. Pratt said, “Health insurers have been doing everything possible to encourage exchange enrollees to pay their premiums.”
Paul Wingle, the executive director of exchange operations and strategy at Aetna, said: “As of the third week of April, Aetna had over 600,000 members who had enrolled and roughly 500,000 members who had paid. For those who had reached their payment due date, the payment rate, though dynamic, has been in the low- to mid-80 percent range.”
Aetna said it was selling insurance to individuals and families in the exchanges of 17 states.
The Obama administration extended deadlines for people to sign up and pay for insurance, making it difficult to establish an accurate count of enrollment, insurers said. The federal government is still working on a financial management system to reconcile enrollment records of insurers and the exchanges.
Confirmation Hearings Loom for Health Services Nominee
By ROBERT PEAR
WASHINGTON — Sylvia Mathews Burwell, President Obama’s nominee for secretary of health and human services, will undergo the first of two Senate confirmation hearings on Thursday, with lawmakers from both parties hoping she can improve relations between the administration and Congress on health care.
Ms. Burwell, 48, a native of Hinton, W.Va., is to be introduced by the state’s senior senator, Jay Rockefeller, a Democrat. Democrats said they hoped she would also be introduced by Senator John McCain, Republican of Arizona, who has described her as “an excellent choice” to be health secretary.
Senator Tom Harkin, Democrat of Iowa, said Ms. Burwell was “eminently qualified” to lead the sprawling agency. The Department of Health and Human Services provides insurance to more than 100 million people through Medicare and Medicaid, regulates food and drug products that account for roughly one-fourth of consumer spending, and sponsors biomedical research that has saved or extended millions of lives.
Mr. Harkin is chairman of the Committee on Health, Education, Labor and Pensions, which is holding the session on Thursday. The Senate Finance Committee plans to hold a separate hearing on Ms. Burwell’s nomination soon.
Ms. Burwell, a Harvard graduate who attended Oxford University as a Rhodes scholar, is the director of the Office of Management and Budget; the Senate confirmed her for that job in a 96-to-0 vote in April 2013. She also worked in the Clinton White House, at the Walmart Foundation and at the Bill and Melinda Gates Foundation.
The earlier unanimous vote does not guarantee smooth sailing this time. Republicans hope to win a Senate majority in November on the strength of their opposition to the health care law, and they have made it clear that they will use the confirmation hearings as a forum to investigate the law’s operations, including the penalties for people who go without insurance and for larger employers that do not offer coverage to full-time employees.
Pick to Replace Sebelius Draws Senators’ Praise at Confirmation Hearing
By ROBERT PEAR
WASHINGTON — Sylvia Mathews Burwell, President Obama’s nominee to replace Kathleen Sebelius as secretary of health and human services, charmed senators at a surprisingly cordial confirmation hearing on Thursday.
And she even picked up a couple of Republican endorsements.
“Regardless of my objections to the Affordable Care Act, the Department of Health and Human Services needs competent leadership,” said Senator John McCain, Republican of Arizona. “I believe Ms. Burwell has the qualifications to run Health and Human Services.”
Senator Richard M. Burr, Republican of North Carolina, said he intended to vote for Ms. Burwell because she had “a portfolio of experience that would make her a tremendous asset” to the Department of Health and Human Services.
Ms. Burwell, 48, has been Mr. Obama’s budget director for the last year. Senator John Barrasso of Wyoming, a point man for Republicans on health care, said he voted for her to be director of the Office of Management and Budget in April 2013. Without making a commitment to vote for her this time, Mr. Barrasso said, “She’s a capable individual.”
The nominee clearly benefited from the contrast with Ms. Sebelius, whose relations with Republican lawmakers ranged typically from strained to nonexistent.
Mr. McCain said Ms. Burwell had assured him that “she will work with members of Congress, as she has as director of O.M.B., and be more responsive to its members than her predecessor.”
The hearing was held by the Senate Committee on Health, Education, Labor and Pensions, headed by Senator Tom Harkin, Democrat of Iowa. The Senate Finance Committee plans a separate confirmation hearing, perhaps as early as next week, and Democrats hope Ms. Burwell may be approved this month. For the Senate, that would be breakneck speed.
‘Fed Up’ Asks, Are All Calories Equal?
Those predictions drew immediate fire from Insurance Commissioner Dave Jones. He said the concerns are nonsense and passage of the ballot measure is essential for consumers to reap the full benefits of the Affordable Care Act.
For two years, Jones and consumer groups have campaigned for more authority over ever-increasing health premiums for consumers and small businesses. In November, voters will decide whether to give the insurance commissioner veto power over rate hikes.
The latest dust-up stems from a report being issued Thursday by health insurers and other business groups opposing the ballot measure.
The report's author, the former head of the Massachusetts health exchange and an adviser to the Obama administration on the Affordable Care Act, said passage of the ballot initiative would conflict with California's new health exchange, which exceeded expectations in signing up 1.4 million people in its first year.
In particular, consultant Jon Kingsdale zeroed in on a provision of the initiative that would give outside groups the opportunity to legally challenge rates under consideration by the insurance commissioner.
The prospect of lengthy legal wrangling could severely disrupt the ability of the Covered California exchange to negotiate premiums with health plans and meet its deadlines for open enrollment, Kingsdale said.
"Trying to overlay these two conflicting approaches at the same time is highly problematic," Kingsdale said in an interview. "There's nothing like this in any other state."
If an insurer couldn't get rates approved on a timely basis, he said, it could be shut out of the exchange for an entire year. The overall uncertainty could make it difficult to calculate federal subsidies for consumers because they are pegged to the range of prices in the exchange.
Opinion Obamacare may prevail in court, but can it survive rising premiums?
by JON HEALEY
A consistent theme in the legal challenges to the 2010 Patient Protection and Affordable Care Act is that Democrats in Congress or the Obama administration cheated in some way to enact or implement the law. The arguments go something like this: Congress overstepped its constitutional authority to regulate interstate commerce by requiring Americans to buy insurance. The administration improperly rewrote the law by issuing rules that don't comply with the law's text. And in two cases heard Thursday in the U.S. Court of Appeals for the District of Columbia Circuit, Democrats are alleged to have ignored the constitutional requirement that all revenue bills originate in the House, and the administration is accused of breaking the rules on religious freedom in its zeal to make insurance plans cover contraception with no out-of-pocket costs.The argument with the best chance of prevailing is the complaint by church-affiliated employers against just a portion of the law, the contraception mandate (for the record, The Times' editorial board supportsthe mandate with the narrow exemptions the administration has provided). The other challenges, which strike at the core of the law, have already been rejected or seem like long shots. The true existential threat to Obamacare is much more likely to come from rising health insurance premiums. But more on that later.
Here's what I mean by a legal long shot. One of the cases heard Thursday is a lawsuit by an artist in Washington state named Matt Sissel, who initially challenged the individual mandate on the grounds that it violated the Constitution's commerce clause. When the Supreme Court held that the mandate was a constitutional use of Congress' power to tax, Sissel and his lawyers at the Pacific Legal Foundation shifted gears, arguing that the measure originated in the Senate, not the House, in violation of theorigination clause in Article I. For those who don't have Article I memorized, said clause states, "All Bills for raising Revenue shall originate in the House of Representatives; but the Senate may propose or concur with Amendments as on other Bills.” (The founders really liked capital letters.)
I blogged about the lawsuit last year, after District Court Judge Beryl A. Howell (one of President Obama's appointees) rejected Sissel's claim. Howell wrote that the origination clause challenge failed because the purpose of the ACA was not to raise revenue, and because the bill in question (HR 3590) did, in fact, originate in the House. Granted, the House-passed version would have extended a tax break for veterans, but it also included provisions to raise revenue to offset the tax break's cost.
The Pacific Legal Foundation argues in its appeal that Howell misinterpreted the precedents on the issue, which it claims require any Senate amendment to a House revenue bill to be relevant to the topic addressed by the House. But if the foundation is correct, it would read a germaneness requirement into the origination clause that the founders didn't write.
LePage’s 182 vetoes are bad for business
Posted May 02, 2014, at 8:28 a.m.
Gov. Paul LePage’s desire to improve Maine’s business climate is well noted. He sold voters on a business-friendly platform and his credentials as former general manager of Marden’s; launched “red tape” workshops for businesses to identify ideas for regulatory changes; designated “account executives” to reach out to businesses; and has stressed the need for lower energy costs and taxes to benefit businesses. In a symbolic gesture, he championed the well-known sign on I-95 in Kittery that declared the state “open for business.”
But when LePage vetoes 182 bills, it hurts his goals of growing jobs and enticing future businesses and employees to the state. Whether large or small, business owners need to know they can count on a functioning, predictable government. A record number of vetoes shows a vast disconnect between the executive branch and the Legislature, making it far harder than it already is to pass legislation. There are many deterrents to opening, growing or relocating a business, and the appearance of a dysfunctional government is a big one.
Some have pointed out that Democratic lawmakers proposed bills they knew wouldn’t pass LePage’s desk, to use in campaign material against him this November. There is some truth to that idea. (Consider, for instance, a bill to study transitioning Maine to an entirely government-run health care system, as opposed to having employer-sponsored health insurance.) In the same vein, Republican lawmakers proposed bills they knew had no
New push for state-funded health care
By Kelly Fay
The Legislative Gazette (Albany, N.Y.), May 6, 2014
Lawmakers, patients and health providers are urging the Legislature to pass a bill they say would provide every New Yorker with the basic human right to health care. Advocates rallied outside the Capitol Tuesday demanding the state adopt a single-payer system of health insurance and put "patients before profits."
The universal health insurance bill, also known as New York Health, would streamline coverage for New Yorkers by replacing existing private and state health care programs with one universal program paid for by the federal and state governments. In order to do so, the state will need a waiver so that federal funding streams for specific programs can be pooled and applied toward statewide health coverage.
The concept for the bill (A.5389-a/S.2078-a) was initially introduced 23 years ago, and passed in the Assembly in 1992. However, it has not been brought to the floor for a vote since. Currently, New York Health has received the official support of 72 assembly members, but activists are confident it would pass if a vote is allowed.
Chair of the Assembly Health Committee and sponsor of the legislation Richard Gottfried said great strides were made with the passage of the federal Affordable Care Act, but more needs to be done.
"What is now crystal clear to everyone is that while you can patch it up, the system still does not work," said Gottfried, D-Manhattan. "We do not need health insurance companies. We need to recognize that health care is a human right, not a commodity."
Similar measures have been introduced in 26 states, but only one — Vermont — has passed legislation instituting a single-payer program. Vermont is expected to launch the program in 2017 once it has received the proper federal waivers. In California, the Legislature has passed universal health care bills twice, but the legislation did not received the support of Gov. Arnold Schwarzenegger.
According to a 2009 study by the Urban Institute and funded by the New York state Legislature, the state could cut health care expenses — whether agency, employer or individual — by $20 billion if a single payer program were adopted.
According to Laurie Wen, executive director of the NY-Metro chapter of Physicians for a National Health Program, under a single payer system, some people, primarily wealthier individuals, may see an increase in taxes. However, she explained, other costs such as deductibles, premiums, out-of-network charges and co-pays would no longer be an issue.
More importantly, she said, the system would save the lives of six people a day who die because they do not have health coverage, and provide everyone with the same freedom of choice when choosing a physician.
http://www.pnhp.org/print/news/2014/may/new-push-for-state-funded-health-care
The Legislative Gazette (Albany, N.Y.), May 6, 2014
Lawmakers, patients and health providers are urging the Legislature to pass a bill they say would provide every New Yorker with the basic human right to health care. Advocates rallied outside the Capitol Tuesday demanding the state adopt a single-payer system of health insurance and put "patients before profits."
The universal health insurance bill, also known as New York Health, would streamline coverage for New Yorkers by replacing existing private and state health care programs with one universal program paid for by the federal and state governments. In order to do so, the state will need a waiver so that federal funding streams for specific programs can be pooled and applied toward statewide health coverage.
The concept for the bill (A.5389-a/S.2078-a) was initially introduced 23 years ago, and passed in the Assembly in 1992. However, it has not been brought to the floor for a vote since. Currently, New York Health has received the official support of 72 assembly members, but activists are confident it would pass if a vote is allowed.
Chair of the Assembly Health Committee and sponsor of the legislation Richard Gottfried said great strides were made with the passage of the federal Affordable Care Act, but more needs to be done.
"What is now crystal clear to everyone is that while you can patch it up, the system still does not work," said Gottfried, D-Manhattan. "We do not need health insurance companies. We need to recognize that health care is a human right, not a commodity."
Similar measures have been introduced in 26 states, but only one — Vermont — has passed legislation instituting a single-payer program. Vermont is expected to launch the program in 2017 once it has received the proper federal waivers. In California, the Legislature has passed universal health care bills twice, but the legislation did not received the support of Gov. Arnold Schwarzenegger.
According to a 2009 study by the Urban Institute and funded by the New York state Legislature, the state could cut health care expenses — whether agency, employer or individual — by $20 billion if a single payer program were adopted.
According to Laurie Wen, executive director of the NY-Metro chapter of Physicians for a National Health Program, under a single payer system, some people, primarily wealthier individuals, may see an increase in taxes. However, she explained, other costs such as deductibles, premiums, out-of-network charges and co-pays would no longer be an issue.
More importantly, she said, the system would save the lives of six people a day who die because they do not have health coverage, and provide everyone with the same freedom of choice when choosing a physician.
http://www.pnhp.org/print/news/2014/may/new-push-for-state-funded-health-care
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