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Voices Speaking

January 15, 2019

Healthcare in 2019 - What to Expect

Karen Siegel, M.P.H.

Health insurance coverage rates are slipping

Connecticut’s HUSKY (Medicaid and CHIP) programs are key to our state’s health and economic success. Medicaid coverage has an enormous impact: it reduces poverty, provides lifelong benefits for children, and helps to reduce infant mortality rates. Children are more likely to have insurance and to see a doctor when their parents are insured; so, covering whole families is especially important. Being insured means parents with chronic conditions can stay healthy enough to work and parent well. It also means freedom from exposure to catastrophic medical debt for families and less uncompensated care for hospitals and clinics. Further, Connecticut’s HUSKY program is fiscally efficient, boasting the lowest per member per month Medicaid costs nationwide.

HUSKY expansion helped raise the rate of Connecticut residents who have health insurance to one of the highest in the nation. Yet, recently released 2017 American Community Survey data suggests that while insurance coverage rates in the nation continue to improve, in Connecticut they are at best stable and likely decreased by roughly 20,000 individuals from 2016 to 2017.

Since 2015, the legislature has twice voted to cut Medicaid income eligibility levels for parents/caregivers. We cannot afford to balance the state budget by putting families at risk of preventable disease and economic instability.

Health insurance quality at risk

Having health insurance helps people access care, but being insured alone is not enough. For Connecticut’s families to avoid preventable illness or complications, health insurance must pay for services that families need to stay healthy. Proposals at the state and federal levels threaten to erode what it means to have health insurance coverage. These include allowing short-term and “junk” insurance plans, consolidation of providers through hospital mergers and the Aetna/CVS merger—which could limit access and increase costs, and efforts to trim the state budget by covering fewer benefits for Medicaid enrollees. 

When parents have to choose between paying out of pocket towards a high deductible or paying a utility bill, they are likely to forgo or put off treatment. Inexpensive measures that could prevent a crisis—like a vaccination or a checkup—keep health care costs down.

Recent attempts to trim the Medicaid budget have targeted dental coverage and primary care provider rates. When Connecticut raised Medicaid reimbursement rates for primary care, provider participation increased, meaning more Medicaid patients were able to make appointments for routine care. Given the state fiscal crisis, Medicaid is likely to be targeted again. Additional cuts will cause real harm to real families.

Connecticut should join nearby states by adopting paid family and medical leave

Paid parental leave leads to a host of positive life outcomes for both parents and children, including decreased infant mortality, decreased child behavioral problems, decreased rates of maternal post-partum depression, and increased rates of father involvement throughout childhood. Children begin building vital brain architecture from the time they are born. By giving parents time to develop secure attachments with their new child, family and medical leave plays an important role in nurturing healthy child development for biological and adoptive parents.

Often, workers lacking paid family and medical leave hold low-income and/or multiple part-time jobs, and so cannot afford to take time off. Workers who take time off with no pay or reduced pay report borrowing money, enrolling in public assistance, putting off paying bills, and cutting their leave short. Family medical leave strengthens families’ economic stability and alleviates stress by allowing parents to care for their children without financial hardship.

Further, paid family medical leave is a smart way to improve Connecticut’s workforce. Access to paid family medical leave results in workers taking better care of their health, taking fewer risks, taking fewer and shorter sick leaves throughout the course of their careers, and having less inpatient care. Further, leave is paid for by employees, as detailed in the plan Connecticut has come close to adopting.

Opportunities to promote healthy, stable, and safe communities

Racial and ethnic disparities in health cannot be addressed in the clinic or hospital alone. To promote health equity, it is necessary to enhance community-based services and connect people to what they need in the places where they live, play, study, and work. For example, by connecting the parent of a child with chronic asthma to resources that can remove mold or offer pest-control for the family home, emergency room visits can be decreased while the family’s wellbeing increases. Community health workers can help bridge the gap between doctors’ visits and life at home, helping to identify non-medical causes of health issues and find resources to address these. Community health workers can also help empower families to play a bigger role in their care or help families to incorporate lifestyle changes in response to a diagnosis or addiction.

Opportunities to promote these strategies and to link communities to medical providers and vice versa include soon to be released proposals by the Office of the State Health Innovation Model, the recently announced federal Integrated Care for Kids grant and recently passed federal funding to address opioid addiction.

Opportunities to promote lifelong mental health starting at birth

In the first thousand days of life, children’s brains develop rapidly, making this period an especially important one for promoting health and preventing illness. Identifying and addressing children’s and families’ needs early on can prevent a lifetime of struggling to learn or coping with mental health challenges. Whole-family approaches can support children in developing resilience and other protective factors while supporting caregivers to respond to challenges in productive ways.

Opportunities to access additional federal funding mentioned above and through the Families First Prevention Services Act could also be used to bolster our state’s behavioral health system, especially for young children. Connecticut is poised to take advantage of these resources and to leverage the State Health Innovation Model to promote positive outcomes for children by improving the links between pediatricians’ offices and the state’s home visiting and community-based early childhood efforts.  Connecticut is the birthplace of robust, best-practice initiatives like Help Me Grow and Birth to Three and home to an array of home-visiting and screening programs, but these programs remain underfunded and links between programs, schools, and medical care providers could be improved.   

Issue Area:
Health
Tags:
health, Healthcare, HUSKY, insurance
December 19, 2018

Updates: Farm Bill Passes and Legal decision on the Affordable Care Act to be Appealed

Karen Siegel, M.P.H.

It was a busy week in national health news. First, the long-stalled Farm Bill, which includes SNAP (Supplemental Nutrition Assistance Program, formerly Food Stamps), passed both houses of Congress. The final bill is a bipartisan compromise that preserves SNAP without imposing the draconian cuts included in earlier drafts.  This means that Connecticut families can continue to count on SNAP to put food on the table in lean times.

On the day the President is expected to sign the Farm Bill into law, the USDA announced a proposed rule to restrict states’ ability to provide SNAP benefits to adults without dependent children living in high-unemployment areas. This rule, which would affect roughly 39,000 Connecticut residents, will be posted for public comment in the near future.

Also last week, a judge in Texas declared the Affordable Care Act (ACA) unconstitutional. The ruling found that without the tax penalty for failing to purchase health insurance, which ends this year, the entirety of the Affordable Care Act cannot stand. Legal experts have responded by calling the ruling unsound. Should this ruling eventually take effect, it would abolish Medicaid expansion (HUSKY D in Connecticut), health insurance subsidies, and consumer protections, affecting hundreds of thousands of Connecticut residents.  The good news:  For now, nothing changes while the decision works its way through the appeals process. Individuals who are uninsured can still sign up for health coverage through Connecticut’s health insurance exchange, Access Health CT, through January 15. Many qualify for subsidies through the exchange. Residents may sign up for HUSKY throughout the year. 

Issue Area:
Health
Tags:
ACA, farm bill, food stamps, health, SNAP
November 19, 2018

Public Charge: Submit your comments today

Karen Siegel, M.P.H.

We have written before about proposed changes to the public charge determination used when individuals seek a change in their immigration status.

Connecticut Voices for Children recently prepared these comments for the Federal Register. To make the comment writing simpler for partners, we also created this template. Submit your comments here by December 10. Please share your story or experience before the December 10 deadline.

For more information on public charge, please see this FAQ sheet from Greater Hartford Legal Aid in English and Spanish, and our previous blog posts here and here.  

 

Issue Area:
Health
October 17, 2018

Public Charge Open for Comments: Rule change would discourage non-citizens from using social services

Karen Siegel, M.P.H.

A few weeks ago, we posted about the “public charge” determination and proposed changes to this rule. The comment period on this rule change began this week and is open until December 10.

Specifically, how would the “public charge” determination change?

The proposed changes would continue to rely on “totality of circumstances” in making immigration decisions. However, they would:

  • Change the threshold from an applicant being “primarily dependent on” to being “likely to receive” a public benefit

  • Expand the list of benefits considered to include Medicaid, SNAP, housing assistance, and more

  • Consider factors such as health, age, and English proficiency

  • Impose a specific income test that makes those earning less than $26,000/per year for a family of three less likely to be approved

These changes include a complex set of rules designed to disqualify immigrants of low to moderate income and favor those with higher incomes (over $52,000/year for a family of 3). The “public charge” determination is considered when a lawfully present immigrant applies for a change in status (for example when applying to change from a student visa to Lawful Permanent Resident status or “green card” holder, or when a “green card” holder leaves the country for more than 180 days and seeks to reenter). See these scenarios explaining when and to whom these rules apply.

The end result will most likely be children and families going without health insurance and other key supports for fear of repercussions, whether or not the rules apply to their circumstances.

How would these changes impact children in Connecticut?

Connecticut’s current laws and rules provide extremely limited access to social services and public health insurance for non-citizens. Nonetheless, there are reports that the rule is already causing confusion, fear, and disenrollment. In Connecticut, an estimated 87,000 children who have at least one non-citizen parent live in families enrolled in a benefit program such as Medicaid (our state’s HUSKY program) or SNAP.  Even though very few of those families would be subject to a public charge determination, the rules are confusing. As a result, the state’s rate of families without insurance or access to adequate nutrition is likely to increase.

Connecticut Voices for Children will submit comments to the federal register and will share our comments here.

Take Action:

Issue Area:
Health
Tags:
Benefits, immigration, Medicaid, public charge, SNAP
September 25, 2018

What is Public Charge?

Karen Siegel, M.P.H.

“Public charge” is a term used by immigration officials to determine that a person seeking to enter the United States, immigrate, or apply to become a Legal Permanent Resident or “green card” holder is or is likely to be dependent on public services.

To date, this determination has included only cash assistance (such as SSI and TANF) and publicly funded long-term institutional care. On Saturday, the Department of Homeland Security issued a press release and text of proposed changes to the “public charge” rule.

 

It is important to note that these changes are not yet in practice. Before changes can be implemented, the administration must give the public 60 days to comment on the proposed rule, consider those comments, and then wait at least 60 days after posting the final rule before implementing changes.

 

What changes have been proposed?

If undertaken, proposed changes would expand the benefits included in a determination of “public charge” to include:

  • Non-emergency Medicaid (with limited exceptions)
  • The Supplemental Nutrition Assistance Program (SNAP)
  • Housing assistance such as Section 8 housing vouchers
  • Low-income subsidy for prescription drug costs under Medicare part D

The draft also asks whether or not the Children’s Health Insurance Program (CHIP) should be included. Additional details about changes to how the rule is applied and to whom are available here.

 

Who would these changes impact?

These changes would affect individuals seeking a change in immigration status, though it does not apply when “green card” holders apply to become citizens.

The public charge statute requires immigration officials to consider overall circumstances, not just the use of services, in making an immigration status decision.  Finally, these changes would not be retroactive; so, they will only apply to enrollment in the specified services after the final rule takes effect.

In Connecticut, many lawfully present “qualified non-citizens” (see definition here) are eligible for enrollment in the state’s Medicaid and SNAP programs.

 

Who is exempt from a public charge determination?

Some groups—such as refugees, asylees, and other protected groups—are not subject to “public charge.”

Further, the determination will consider use of benefits by the individual applicant – not by family members.

Click here for more details about which groups are exempt and a detailed list of relevant programs.

 

Why do the changes to this rule matter?

The primary cause of concern is that fear of a potential rule change and confusion about what has not been changed will lead to lower rates of enrollment in programs that help families meet their basic needs—including SNAP and Medicaid. This “chilling effect” is already taking place according to some reports.

Should the draft rule take effect, lawfully present immigrants who work in low-paying jobs will be forced to choose between obtaining vital services and their immigration status. Many will likely stop using or fail to enroll in health insurance or nutrition programs for themselves or their families for fear that the rules may change again. Such uncertainty adds to the daily stress of living in an immigrant family in today’s political climate.

In Connecticut, 81,000 citizen children who have at least one non-citizen parent are enrolled in Medicaid or CHIP. Children make up 40% of the national Medicaid population and account for just 19% of Medicaid spending. Yet, the services they receive can have lifelong benefits. Further, when parents are uninsured, eligible children are less likely to be insured or see a doctor. Thus, this rule change jeopardizes the health and wellbeing of thousands of Connecticut’s families.

Providing access to health care and nutritional support for non-citizens is an investment in our state’s future and enables families to continue to work and contribute to the economic and social wellbeing of our state.

 

What can you do?

1.    Prepare to comment on the proposed rule change once it is posted—sign up for alerts here.

2.    Help to correct confusion about what the current rule is and who the changes would affect.

3.    Contact Senator Blumenthal, who serves on the Immigration Subcommittee of the Judiciary Committee, to thank him for his defense of our nation’s tradition of welcoming immigrants.

Issue Area:
Health
September 7, 2018

Connecticut Strives for Primacy of Health Equity in Primary Care

Karen Siegel, M.P.H. and Tekisha Dwan Everette, Ph.D., Executive Director, Health Equity Solutions; Eva Marie Stahl, Ph.D., Project Director, Community Catalyst

Connecticut’s federally funded effort to introduce primary care innovations (through the State Innovation Model or SIM grant) is entering its final years of implementation. In the coming months, the state will present and finalize its proposals (to review and comment on proposals as they are released, see here). Right now is an opportune time to ensure these proposals can transform Connecticut’s health system to promote equity by investing in prevention and addressing social and economic factors that make some in our state far less healthy than others.

As a reminder, many states applied for the federal SIM grant funds to advance health reform. Connecticut has used this funding as an opportunity to explore new models of primary care delivery with a focus on health disparities. Specifically, SIM piloted a primary care health home model that incorporated community health workers into the care team for some patients. As with any pilot or model, there continue to be bumps that need smoothing and culture that needs shifting. The premise, however, is solid: the current system does not do enough to reduce the deep disparities in both individual and population health that reverberate through communities of color. Specifically, the current system does not do enough to connect families with community-based services where they live. 

Commitments to any one payment model can serve as a barrier to improving health outcomes. The fee-for-service approach of the Medicaid payment system is limited in flexibility and for too long some have safeguarded it as the only viable path. This is not an “us” against “them” situation but rather a recognition that, in its current form, fee-for-service is a barrier to scaling up efforts to connect primary care with community-based services in long-term and meaningful ways. With an innovative approach, Connecticut can adapt the state’s health systems to the needs of all of our residents while simultaneously safeguarding access to quality health care and vital services.

As advocates and stakeholders disagree about what payment or delivery system approach will meet the triple aim of lower cost, high quality care while maximizing access – the question is: what do consumers want? What do consumers need? And how do consumers define success? And if the goal is to center on health equity in this work, what systematic and systemic changes are needed? Connecticut’s approach of focusing on primary care to meet these needs is admirable. Primary care is the first touch point for many people when they interact with the health care system and a venue of frequent contact with parents and young children. It is also a space ripe for culture change given the right supports. A whole-family and integrated care approach is, without a doubt, the future of health care delivery and what is needed to advance health equity in Connecticut.

How we get there while ensuring that any system reflects the needs and wants of consumers themselves is less clear. Listening to consumers is hard work; it requires patience, resources and time to build trust. Specifically, it is essential to build trust with communities of color and those communities left out of economic progress; it also demands a long-term commitment from key stakeholders and decision makers. Finally, it requires advocates and stakeholders to be listeners and innovators.

As Connecticut’s decision makers contemplate next steps regarding how to implement some of the learnings from their SIM work over the next six or so months, those advocating for better care and health equity should consider what mechanisms would support needed changes that reflect consumer feedback. Reconsidering the pathways – the “how” – as we forge ahead with advocacy in a financially scarce environment will be important to meeting our goals for health equity and readying the system for more ambitious work around social determinants of health. Let’s get to work together.

 

Tekisha Dwan Everette, PhD*, Executive Director, Health Equity Solutions and Karen Siegel, M.P.H., Health Policy Fellow, Connecticut Voices for Children contributed to this blog as guest bloggers.
*Dr. Everette is a subcontractor with the Consumer Advisory Board but the opinions written here are wholly her own and do not represent any other entities.

Click here to see the original blog post on Community Catalyst's website.

Issue Area:
Health

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