Since the 2010 mid-term elections when control of the U.S. House of Representatives flipped from Democrats to tea party-dominated Republicans, Washington politicians have been engaged in an ongoing war over whether, when, and how best to reduce the annual federal budget deficit.  Health care programs such as Medicare, Medicaid, the State Child Health Insurance Program (SCHIP), and the Affordable Care Act (ACA) sit squarely in the middle of the struggle given their combined significance in the overall budget.

In the various pieces of deficit reduction legislation enacted since over the past 3 years (the Budget Control Act of 2011, the American Taxpayer Reduction Act of 2012, and the FY 2014 and 2015 appropriations bills enacted this past January), these health care programs have been held relatively harmless.  There have been some modest cuts in provider reimbursement rate in Medicare, and some diversions of ACA-related funding dedicated to new public health initiatives, long-term care insurance programs, and new non-profit “insurance co-ops” set-up in many states.  (Ours here in New York is “Health Republic”.)

The general annual federal budget process begins when the president releases his proposals in late winter, followed by each house of Congress developing and adopting their own one-house resolutions in the early-mid spring, which are just spending and policy blueprints without details.  Then a conference committee meets to develop an agreed-upon budget that each house then approves by late spring.  A presidential signature is not required since it is just a guidance document for going forward in the process.  Congressional leaders and administration officials then meet over the summer to hammer out specific appropriations bills based on their proposals.  Their final agreement then goes to Congress for adoption by Oct. 1^st, when the federal government’s new fiscal year begins.

In his budget for the coming FY 2015, President Obama has left Medicaid, SCHIP, and the ACA largely as is, with no significant changes.  His proposals for Medicare are to reduce spending by $400B over a 10-year period through the following major initiatives:

• Reductions in payments for prescription drugs ($136B), most of which would result from raising rebates for drugs provided to low-income people on Medicare ($116B).
• Reductions in payments to providers ($132B), most of which would result from post-acute care services ($104B).
• Increases in premiums, deductibles, and co-pays for upper-income beneficiaries ($64B)
• Reductions in subsidies to private insurers who participate in the “Medicare Advantage” program ($32B)
• Lowering the overall target annual growth rate for Medicare from GDP+1% to GDP+0.5% ($12B)

The President also proposed to end ongoing sequester cuts to Medicare.  Overall, his proposals mirror those he’s put out in previous years.

In early April, before recessing for the Easter-Passover break, the House of Representatives adopted its own budget, with the following health care provisions:

• Repeal of the ACA, including ending funding for: 1) state Medicaid expansions; 2) premium subsidies for private plans; 3) closing the Medicare Part D coverage gap (“donut hole”); and 4) Medicare preventive services.
• Transforming Medicaid from an entitlement program that grows to meet demand into a flat block grant to states, with weaker federal rules and oversight.
• Folding SCHIP into Medicaid while ending SCHIP funding per se.
• Reduction in Medicaid spending by 26% over the next 10 years ($1.5TR).
• Transforming Medicare into a flat-rate voucher program to buy into either private insurance plan or Traditional Medicare.  It would start in 2024 for new beneficiaries, and the vouchers would be indexed to the general inflation rate (instead of medical inflation, which is typically 2-3 times higher.)
• Raise the Medicare eligibility age from 65 to 67 over a 10-year period, starting in 2024.
• Raising premiums for upper-income beneficiaries starting in 2019, and lower the income thresholds that trigger such them over time.
• Sequester cuts to Medicare remain in force through 2024.

The Senate leadership has indicated they will not be developing a budget proposal this year in lieu of the budget and appropriations bills enacted in January.  Accordingly, both the President’s budget and House budget are mainly seen as campaign manifestos for this fall’s mid-term Congressional elections, and neither differ much from recent years.  Not much activity is expected in the budget process from here forward until at least the late fall.  Therefore, the next meaningful budget fight likely won’t start up until a year from now when efforts to craft a budget for FY 2016 gets underway.

The outcomes of the upcoming elections will determine who gets to put what on the table then, and what ideas (good or bad) move forward.  If “pro-health care” candidates prevail, the Affordable Care Act and its provisions improving Medicare and Medicaid will proceed, and SCHIP will continue as is.

Reference sources:  Center on Budget and Policy Priorities, Families USA, Kaiser Family Foundation

A day after all “open enrollments” finally ended in New York, participants in the “Get Covered New York” (GCNY) project gathered on the evening of April 16 to celebrate their successful outreach efforts to uninsured New Yorkers about new health care coverage options available in New York under the Affordable Care Act (ACA).   Over food and drink in a loft in Manhattan’s Chelsea district, they shared food, drink, and moving and humorous stories of their experiences over the past year.  Joining them were colleagues from similar efforts across New York City spearheaded by Enroll America and Organizing for Action.

GCNY was launched in the spring of 2013 as a joint initiative between New York City-based organizations active in the leadership of Health Care for All New York, and community-based activist groups affiliated with Greater NYC for Change.  The project’s goals have been to educate the public about new ACA-authorized plans available to New Yorkers, and outreach to the uninsured in community settings and directing them to various in-person assistors to help them get enrolled in coverage.

Initially, GCNY set up a simple website and developed basic educational and outreach materials.  They next trained over 120 volunteers on the basics of ACA coverage who then hit the streets over the course of the summer and fall of 2013, showing up across the city at street fairs, church socials, community festivals, soup kitchens, food pantries, health fairs, concerts in parks, and the like – over 80 events in total, many in neighborhoods with high rates of uninsured.  They collected contact information from uninsured people as they went, compiling them into a database of over 4,000 names.  Once open enrollment began on October 1^st, they began to contact these people back via weekly phone banks and email reminders, leading to over 1,500 phone conversations alone.  They not only urged people to get enrolled, they also collected personal stories from some, comparing the “anxious before” and “relieved after.”  Many who were called said they very much appreciated the tenacity of GCNY volunteers, and the help and encouragement they provided.

According to the New York State Dept. of Health, over 960,000 New Yorkers statewide have now enrolled in health plans, approximately 70% of them being previously uninsured.  GCNY participants took some well-deserved credit for a portion of those numbers.  They vowed to next shift their outreach efforts to target low-income people who can still sign-up for Medicaid, as well as small business owners and operators who can continue to enroll their employees into coverage.

It’s a whole new day (and government) in New York City in 2014!  With a new Mayor, Public Advocate, Comptroller, Council Speaker, and 21 Council Members, most of whom are proudly self-proclaimed political progressives, hopes are running high that significant strides can be made to enhance access to health care coverage and services and address outstanding public health problems.

Gathering together under the umbrella of the People’s Budget Coalition for Public Health (PBC), an effort spearheaded by the Commission on the Public’s Health System and the Federation for Protestant Welfare Agencies, a diverse range of health care advocates and their union partners have joined forces to craft a proactive budget agenda which they are sharing with City Hall officials and their staffs with an eye toward influencing their initial budget proposals.  This approach differs from previous years when they usually had to wait for budget proposals to come out before acting in response.

On April 8, PBC members met with City Council central staff for the Health and Finance Committees, and staff for Council Health Committee chair Corey Johnson.  Participating groups included the Center for Independence of the Disabled-NY, Children’s Defense Fund of NY, Choices in Childbirth, Coalition for Asian-American Children and Families, Commission on the Public’s Health System, District Council 37 AFSCME, Doctors’ Council SEIU, Federation of Protestant Welfare Agencies, Greater Brooklyn Health Coalition, Local 420 DC 37 AFSCME, Manhattan-Staten Island Area Health Education Center, Metro NY Health Care for All Campaign, NY Immigration Coalition, and the NYS Nurses Association.

The group laid out overall priorities of:

• Increasing democratic control over and community participation in decisions concerning health care resources and public health measures
• Developing preventive health programs that educate and empower local communities in self-care
• Addressing disparities in health, health care, and insurance coverage for racial and ethnic minorities, immigrants, women, children and youth, seniors, people with disabilities, and LGBT people.
• Preserving and expanding the health care safety net, particularly the NYC Health and Hospitals Corporation (HHC)
• Expanding primary care and dental care services
• Addressing the crisis of hospital closures

They also proposed new programs focusing on women of child-bearing age, workforce diversity, community health planning, and community-based outreach to the uninsured to help them access services and enroll in coverage.

Mayor De Blasio released his preliminary budget proposals for FY 2105 back in February.  Various Council committees held hearings on it during March.  City Council staff indicated the Council would be releasing its formal response in late April.  The Mayor’s final budget proposal is due out in early May.  The Council will then hold a second round of hearings before undertaking negotiations with the Mayor in June, with the goal of reaching an agreement by July 1^st when the new fiscal year begins.

Everyone expected a last-minute rush to enroll in new health insurance plans created under the Affordable Care Act as the 2014 deadline for “open enrollment” approached on March 31st.  In the end, many are amazed at the preliminary numbers as they continue to roll in.  Kudos go out to all who helped outreach to the public and who helped uninsured people enroll!

In New York, over 900,000 people have so far enrolled in either Medicaid, Child Health Plus (CHP), or new, private “Qualified Health Plans” (QHPs) through the state’s new health benefits exchange marketplace known as “New York State of Health” (NYSoH).  Approximately another 350,000 or more people remain certified to enroll but haven’t yet completed the process, and they have until April 15^th to do so.  Of the enrollees, over 70% were previously uninsured.  Slightly more than half qualified for public insurance programs like Medicaid and Child Health Plus, with the balance enrolling in QHPs.  No details are yet known about how many qualified for premium subsidies and cost-sharing reductions for QHP coverage, but previous estimates were in the 70-80%  range.

The New York State Dept. of Health has estimated that between 1.6-1.8 million people would enroll in coverage by 2016, so the state is already more than half-way toward it’s goal.  With two more open enrollment periods ahead in the fall of 2014 and fall of 2015, officials are very optimistic going forward.  The state is expected to release more specific demographic data on 2014 enrollees later this month.  Data is still not known about those who enrolled in new health plans outside of the NYSoH exchange marketplace.

Nationally, the Obama administration announced on March 31 that 7.1 million people had enrolled in QHPs through exchange marketplaces, which exceeded their target for 2014.  Since then, two studies have come out expanding on these numbers.  On April 7, Gallup-Healthways Well-Being Index released survey results that the national uninsurance rate fell from 18.0% in Sept. of last year to 14.5% in late March.  Rates fell most dramatically among African-Americans (20.9% to 17.6%), and low-income households making less than $36,000 annual income (30.7% to 27.5%).  On April 9, a survey by Rand American Life Panel estimated a net gain of 9.3 million Americans gaining health coverage as of mid-March, clocking the drop in uninsurance from 20.5% to 15.8%.

While enrollment into private QHPs is now over for 2014, the numbers will continue to rise for the rest of the year because “anytime enrollment” is still possible through NYSoH for those who qualify for Medicaid and CHP, and for small employers (50 or less full-time equivalent employees.)  In addition, individuals and families who may experience a qualifying life event such as marriage/divorce, loss/change of job, relocation to a new state or region, etc. will qualify for a 60-day “special enrollment period” into either a QHP, Medicaid, or CHP.  Further information on these options is available from the NYSoH website and Call Center (855-355-5777), or from the state’s designated consumer assistance program, Community Health Advocates (888-614-5400).

Like smoke rising from a chimney at the Vatican when a new pope is elected, advocates and lobbyists of all stripes await the announcement of a final budget deal with much hope and anxiety, wondering if and to what degree their efforts over a 2-1/2 month period paid off, or will they go home empty handed.

The good news for that this year, much of what health care advocates pushed for was included in the final enacted budget for FY 2015 that began on April 1^st, after being adopted by the State Legislature the day before and signed into law by Governor Cuomo that morning.

Among the health care provisions negotiated between the Governor and legislatures are:

• Authorization to move forward with implementation of a new “Basic Health Program” that will provide very low-cost insurance coverage to people just above the Medicaid level up to 200% of the Federal Poverty Level ($23,000 for an individual, $42,000 for a family of four.)  Estimates are that monthly premiums would be up to $20 per person.  Advocates hope this new program will become available starting in 2015.

• New expanded consumer rights and protections, starting in 2015, for out-of-network services and providers, including:

• Protection from “surprise medical bills” – Consumers will only be responsible for paying the in-network rate for emergency services, and for scheduled services when an in-network provider is not available or the consumer is not informed in advance that out-of-network providers will be involved in providing care.  It will now be up to insurers and providers to resolve between themselves any billing disputes via an independent process, and the patient will be held harmless.

• The right to go out-of-network at the in-network rate – either for services that an insurer’s network doesn’t provide, or when an insurer’s network does not have an appropriate provider in-network.  Out-of-network referrals must be made by in-network providers.  An independent, external review process can be utilized when needed.

• Improved disclosure of information – Insurers must keep their network lists up-to-date (within 30 days), and disclose at what rate they reimburse for out-of-network services (when they are covered.)  Providers must keep their list of what plans they take up to date (within 30 days) and disclose how much they charge for given service when it is provided out-of-network.

• Consumers must be allowed to submit out-of-network coverage requests and claims electronically.

• Insurers that do offer across-the-board out-of-network coverage will have to market at least one plan that provides it at a decent, fairly robust reimbursement level.

• All health care plans will now have to meet the same level of network adequacy standards, whether they are HMOs, PPOs, EPOs, or other types.

• Continued funding for community-based consumer assistance programs across the state.  Now that over 900,000 New Yorkers (and counting!) have gotten health insurance through the “New York State of Health” marketplace, these programs will help them to use their new coverage and troubleshoot any problems with it.  They will also help uninsured New Yorkers to access needed services when they are injured or become ill.  New York’s official program is known as “Community Health Advocates”, a statewide network of non-profits

• A variety of provisions in the budget will be of benefit to people on Medicaid.  Medicaid Matters New York is preparing a summary of them

Finally, while health care advocates are very pleased with these results, many are also very disappointed that the Governor and Legislature refused to move forward on historic campaign finance and ethics reform measures.  These provisions would have enabled a variety of long-stymied measures to move forward in the legislative process, strengthened efforts to combat political corruption, and incentivized community-based leaders to pursue elective office so as to create a state government that is more reflective of the diversity of New York’s population.  In addition, regressive tax measures were enacted that favor the wealthy and large corporations, and further lock-in structural deficits in future budgets, thereby threatening ongoing funding for health care and other social programs in future years.