News & Notes

Kaiser analyses examine impacts of states’ Medicaid expansion decisions: Two analyses from the Kaiser Commission on Medicaid and the Uninsured examine how decisions by states not to expand Medicaid under health care reform will blunt the law's effectiveness in reducing the uninsured population. As of mid-July, 24 states were moving forward with the Medicaid expansion, 21 states were not, and six states were still debating the matter. The Cost of Not Expanding Medicaid found that if the 27 states currently not moving forward or still debating do not implement the expansion, an estimated 6.4 million fewer people would gain coverage—nearly two-thirds of the potential reduction in the uninsured population tied to the expansion. The 21 states would forgo $35 billion in federal funds in 2016 and $345.9 billion between 2013 and 2022, and the six states would forgo $15.2 billion in 2016 and $151 billion over the longer term. The 21-page brief, available at kff.org/medicaid/report/the-cost-of-not-expanding-medicaid, also addresses implications that decisions will have for state spending for uncompensated care and provider revenues. A related brief, Analyzing the Impact of State Medicaid Expansion Decisions, puts these findings in a broader context. The nine-page brief, available at kff.org/medicaid/issue-brief/analyzing-the-impact-of-state-medicaid-expansion-decisions, describes gaps in coverage by race-ethnicity and region. Among currently uninsured Americans whose low incomes would allow them to gain coverage under a state Medicaid expansion, nearly half live in states not moving forward at this time (more than eight in ten uninsured individuals in the South).

Kaiser Foundation’s interactive maps show ACA’s potential impact: An online tool developed by the Kaiser Family Foundation provides detailed projections of the impact of the Affordable Care Act (ACA) on Medicaid enrollment and the uninsured in communities across the nation if a state decides to expand Medicaid. The tool's interactive maps allow users to enter a zip code or city or county name to “zoom in” on a community. Pop-up graphics provide data on Medicaid enrollment and the uninsured population before and after ACA implementation, by race-ethnicity, age, gender, and language spoken at home. An accompanying 25-page report, State and Local Coverage Changes Under Full Implementation of the Affordable Care Act, analyzes these data and discusses policy implications. These resources are available on the Kaiser Foundation Web site at kff.org/interactive/zooming-in-health-reform-medicaid-uninsured-local-level.

Commonwealth Fund report on designs of state-based exchanges: By October 1, 2013, the ACA requires every state to establish a health insurance marketplace (exchange) where individuals and small businesses can shop for coverage. States can create a fully state-based marketplace, enter into a state-federal partnership marketplace, or default to a federally facilitated marketplace. A new report from the Commonwealth Fund, Implementing the Affordable Care Act: Key Design Decisions for State-Based Exchanges, examines structural, operational, and policy decisions made by the 17 states and the District of Columbia that have chosen to establish a state-based exchange. The analysis found that states have made significant progress and that design decisions vary by state. Ten states and the District of Columbia established a quasi-governmental entity to govern the exchange, and the other states chose private nonprofits or state agencies for the task. Every state defined “small employer” as one having 50 or fewer full-time employees. Nearly all exchanges are expected to offer options that give employees a choice of more than one plan, and eight states have provided maximum flexibility by allowing employers to give employees the choice of any plan on the exchange. To help people select and enroll in a plan, 13 states and the District of Columbia have established both a navigator program and in-person assistance program (for those who need more assistance than the navigator can provide); two states will operate only a navigator program for 2014; and an additional two states have not yet finalized their approach. The 27-page report is available on the Web site of the Commonwealth Fund at www.commonwealthfund.org.

RWJF grantees share technology lessons from the Maximizing Enrollment program: In 2009, eight states—Alabama, Illinois, Louisiana, Massachusetts, New York, Utah, Virginia, and Wisconsin—received $1 million grants from the Robert Wood Johnson Foundation’s (RWJF) Maximizing Enrollment program to improve enrollment and retention of children in Medicaid and the Children’s Health Insurance Program and to promote best practices in enrollment simplification. After passage of the ACA, the program’s goal was revised to encompass individuals who would become Medicaid eligible in 2014. Four years later, the grantee states have pioneered innovations by using grant funds to revamp cumbersome, paper-driven enrollment processes, modernize systems, change business processes, and procure new tools. This report, the first in a series of final program reports, shares findings from the grantees’ experiences of piloting technology. The 31-page report describes strategies adopted in four areas: application and renewal technologies, customer interfaces, system functioning, and workflow management. These strategies go beyond what federal law requires and may be useful to other states moving forward with ACA implementation. The National Academy for State Health Policy (NASHP) provided technical assistance and direction to grantee states, and the 31-page report is available on the NASHP site at www.nashp.org/publication/harnessing-technology-streamline-enrollment-experiences-eight-maximizing-enrollment.

SAMHSA adds 300th intervention to NREPP: The Substance Abuse and Mental Health Services Administration (SAMHSA) recently marked a milestone with the addition of three new intervention summaries, raising to 300 the number of interventions included in National Registry of Evidence-Based Programs and Practices (NREPP). The recently added summaries are for Mental Health First Aid, an adult public education program for teaching participants how to respond to individuals experiencing a mental health crisis, Alcohol Literacy Challenge, a brief classroom-based program designed to alter alcohol expectancies and reduce the quantity and frequency of alcohol use among high school and college students, and Creating Lasting Family Connections Marriage Enhancement Program, designed to build or strengthen relationship skills of couples in which partners have been physically or emotionally distanced because of separation due to incarceration, military service, substance abuse, or other circumstances. NREPP was launched in March 2007, and approximately 57,000 individuals visit the Web (www.nrepp.samhsa.gov) each month to access up-to-date, reliable information on the scientific basis and practicality of a range of mental health and substance use interventions.

Bazelon Center’s consensus principles on community integration: In July, as advocates celebrated the 23rd anniversary of the Americans With Disabilities Act, the Bazelon Center for Mental Health Law unveiled a set of consensus principles reflecting the disability community’s vision of community integration. Community Integration for People With Disabilities: Key Principles, available at on the Bazelon Center site (bazelon.org), lays out a vision in which people with disabilities are afforded opportunities to live in their own homes; work in regular, nonsegregated employment; and make their own choices. It calls on government agencies that fund services to support the principles, noting that “Currently, public funding has a bias toward institutionalization, forcing individuals to overcome myriad barriers if they wish to age in place and remain in their communities.” A total of 26 national organizations representing people with disabilities, family members, service providers, and state administrators are signatories.

Webinar on alternative payment models for sustaining integration: Segregated reimbursement for general medical and behavioral health care in the United States is associated with nontreatment of nearly 70% of behavioral health patients and ineffective treatment of another 20%, according to data presented in a Webinar by Roger Kathol, M.D., a specialist in integration strategies in health care. Current attempts to adopt an alternative approach retain segregated reimbursement mechanisms but add special arrangements—“workarounds”—for behavioral health care provided in general medical settings and general medical services provided in behavioral health settings. Dr. Kathol describes the practical manifestations of segregated reimbursement, such as effects on providers’ priorities and treatment quality, and the high costs of not treating mental disorders among patients with chronic medical conditions. He suggests transitioning over the next few years to an alternative model in which behavioral health benefits become part of general medical benefits in one payment procedure—similar to the way in which current payments to separate cost centers like dialysis and physical rehabilitation entities are included in a single procedure. He describes the opportunities created for behavioral health providers and shows how this model can be implemented along with patient-centered medical homes and accountable care organizations. The Webinar is part of a free monthly series archived on the Web site of the Collaborative Family Healthcare Association at www.cfha.net/?page=Webinars.

Center for Health Care Strategies technical assistance brief on “dual eligibles”: State Medicaid agencies are partnering with the federal government to build new approaches to integrated care for individuals enrolled in both Medicare and Medicaid enrollees (“dual eligibles”). Only a few states have integrated programs for dual eligibles, and experience in administering these programs is limited. Leading this activity is the Centers for Medicare and Medicaid Services’ Medicare-Medicaid Coordination Office, which is charged with improving care for this population through new capitated or managed fee-for-service models that integrate financing and service delivery. States pursuing the new models are examining what internal capacity they need. The Center for Health Care Strategies has released a nine-page brief, Building State Capacity to Implement Integrated Care Programs for Medicare-Medicaid Enrollees, that examines key areas in which states will need to build their internal capacity as they pursue integrated care programs for Medicare-Medicaid enrollees. The brief lists questions that states should consider as they assess capacity in several areas: basic organizational capacity (leadership, staffing, and knowledge); contract development, compliance, and oversight; data analysis and information systems; stakeholder communication; rate setting; and quality measurement. Real-world examples are provided from states that have implemented integrated care and managed long-term services and supports programs for this population. The brief concludes that the success of integrated care initiatives for “dual eligibles” will depend largely on the skills and knowledge of state Medicaid staff with regard to Medicare policy and the ability of staff to provide contract oversight, develop competencies in reporting and data analysis, and clearly communicate the value of integration to stakeholders. The brief is available on the Center for Health Care Strategies Web site at www.chcs.org/usr_doc/Building_State_Capacity.pdf.