Health Care in Indian Country: How Medicaid Expansion Can Help

Contemporary American Indian health concerns have been the topic of a four-part newspaper series by Billings Gazette journalist Jayme Fraser. The articles shed light on the decades-long issue of health disparities that are largely grounded in the inability of the Indian Health Service to meet the health care needs of American Indians. They also review various efforts to improve Indian health currently being undertaken by tribes, individual tribal health/IHS facility administrators, and public and private entities, particularly through nationwide healthcare reforms made available through the Affordable Care Act.

One of those measures encouraged states to expand the income eligibility requirements for Medicaid, which the Montana legislature did in 2015. After that, people earning less than 138 percent of the federal poverty level could enroll in Medicaid. This extended critical health care coverage to an estimated 19,547 American Indians in Montana.

Between November 2, 2015, when enrollment began, and September 1, 2016, the number of newly eligible American Indians who enrolled in Medicaid stands at 6,737, or 30 percent of the total number eligible. American Indian enrollment steadily increases each month, though the rate at which they are enrolling is beginning to slow slightly, demonstrating the need for a more concerted outreach and enrollment effort.

Our latest report details some of the ways outreach and enrollment workers can maximize their success in Indian Country. It is paramount that those engaged in coverage enrollment efforts understand the intricacies of how American Indians access health care. For example, knowing that American Indians have historically tended not to have health insurance, relying instead on the Indian Health Service, helps explain why American Indians may be less inclined to explore other coverage options.

Likewise, having an understanding of the historical and contemporary basis of IHS and being able to articulate the precise benefits of having Medicaid coverage are also necessary. It is also important to know the barriers the eligible demographic faces in accessing information and completing the enrollment process.

Besides supporting current outreach and enrollment efforts, the single most important thing the state can do to help the remaining eligible American Indians access the critical health care they need is to maintain the current eligibility requirements included in the HELP Act.

Montana experiences significant positive impacts of Medicaid expansion

Today, the HELP Oversight Committee will meet for its quarterly meeting to review and discuss the implementation of Medicaid expansion in Montana. We’ll get an update on how many people have enrolled, the corresponding reduction in the uninsured rate, and the amount of federal dollars that have flowed into Montana communities for Medicaid provider payments to access affordable health care.

These numbers are impressive – well above initial projections. Tens of thousands of Montanans now have greater access to life-saving services, low or no-cost preventative care, and other health services. We will also hear from hospitals, providers, and others that are seeing the impact of improved access to health insurance.

It will be another year or two before we fully understand the scope of the economic benefits of Medicaid expansion here in Montana, but we can see from other states that the impacts are significant and far reaching. Dozens of studies have been conducted on the effects of expanding coverage, and the Kaiser Family Foundation has compiled a nice summary of that research. Here’s what they’ve found:

States that have expanded Medicaid have seen sharp declines in the number of uninsured adults. From 2012 to 2016, states that expanded Medicaid have experienced nearly 50 percent decline in the uninsured rate for non-elderly adults. This compares with a decline of non-expansion states of about 33 percent. (Because expansion states started at a lower rate, this difference in the decline really understates the effects of expansion, since non-expansion states simply had further room to drop.) States that expanded Medicaid through the federal waiver process, such as Arkansas, are seeing similar increases in coverage.

Individuals are better accessing health services. Some studies have shown that individuals are more likely to access care in expansion states, including finding a personal physician and being able to access needed medication. Additionally, expansion also appears to be having an impact on affordability of care: several studies have found that low-income families report less unmet health care needs because of financial reasons.

More work can be done to provide health insurance education to improve the kinds of services that families are accessing. The great news coming from expansion states is that low-incomes families are utilizing certain types of preventative care more, including dental visits, breast exams, and mammograms. And patients with chronic health conditions are better accessing regular care. However, some states have also seen increases in the use of hospital visits, thus emphasizing that enrollment and health insurance education go hand-in-hand.

Impact on health outcomes continues to be studied. More time is really needed to determine how Medicaid expansion impacts health outcomes; however, initial studies have shown at least some positive impact. For example, as the Kaiser report notes, a study of childless adults living below the poverty line showed that these individuals accessed greater health services resulting in “modest improvements in self-rated health and decreases in the number of work days missed due to poor health.” Similar results were found in a study of individuals who were homeless and accessing life-changing surgeries or treatment otherwise unavailable without insurance.

Economic benefits exceed expectations. States that have expanded Medicaid are experiencing considerable budgetary and economic benefits. The injection of billions of federal dollars into local economies has represented significant economic growth for these states, including growth in states’ gross domestic product (GDP), increased general fund revenue, and the creation of good paying jobs. Several state-specific studies show that these economic benefits will continue, even factoring in the required state match in the later years.

Montana can expect continued economic benefits from Medicaid expansion

States across the country that have expanded Medicaid are experiencing significant savings as well as increased revenue, and as we heard from the Montana health agency this week, we can expect similar experiences here in Montana after the passage of the HELP Act. In case you missed it, MBPC released a new report this week, highlighting the successful enrollment levels in Medicaid – already, over 38,000 Montanans have enrolled– and detailing some effective strategies the state should consider in continuing its outreach to eligible Montanans.

The Department of Public Health and Human Services also announced this week that the State of Montana has already experienced $3 million in savings to the state general fund, and over $37 million in NEW federal dollars invested in communities across the state.

Based on other states’ experiences, Montana can expect continued good news as enrollment grows. A new study out this month shows that all expansion states should expect to see state budgetary savings and additional revenue.

As we’ve talked about before, the federal government pays 100% of the cost of expansion. That match will gradually scale down, but will never drop below 90%. This compares to a federal match of about 70% for the previously eligible Medicaid population. States have been able to “transfer” a portion of that previously eligible population into the new adult group covered at the higher federal match. For the individual, insurance won’t look any different (or in some cases, may be better!), but the state will see savings on what it has to spend on Medicaid. We’ve already seen this in Montana – with the state receiving the higher match for over 8,000 individuals previously covered by Medicaid. This translates to over $3 million in savings to the state general fund.

The report also details additional savings, through lower uncompensated care costs and less pressure on state resources for mental and behavioral health programs, public health programs, and health care services for prisoners. Because many of those who access these programs are now eligible for Medicaid, they can get preventative care and other services they need at lower cost to the state. We don’t yet have data for Montana, but the research shows that savings in other states have exceeded expectations.

Additionally, those new federal dollars into Montana communities have rippling effects all over the state. Even when the federal share scales down to a 90% matching rate, this is still a good deal for states, because these federal funds generate new economic activity that wouldn’t have happened otherwise. A simple comparison is when someone living outside of Montana visits and spends money in the state. Unlike a state resident choosing to spend a dollar in one area of the state economy versus another, our state economy reaps the benefits of that new out-of-state dollar. As the article points out, for every 90 cents in federal funds to pay for one dollar of new Medicaid spending, the state should expect $1.35 to $1.80 in state economic activity, supporting jobs and increasing tax revenues for state and local governments.

Over 38,000 Montanans are getting the health care coverage they need to stay healthy and to be active members of their communities. We’ve heard from many of these folks, who have told their stories about how getting the health services they need has made a real difference. And the fact that the state will see even greater economic benefits than anticipated is “icing on the cake”.

 

Continuing Medicaid Expansion Enrollment: What can we learn from other states?

Without a doubt, the first three months of enrollment in new affordable health care coverage in Montana has been a true success. The state health agency announced yesterday that, as of March 15, over 38,000 Montanans have gained health insurance through Medicaid expansion. Our blog post earlier this week highlighted the majority of these newly enrolled individuals are living in poverty (many in deep poverty), many of whom have never been able to afford health insurance. The enrollment numbers are exceeding expectations, but it was also not surprising that the state experienced strong enrollment during the months that coincided with open enrollment for health insurance on the federal Marketplace.

It is important to note that the enrollment period for Medicaid is year-round, and the state and other partners must continue to look at ways to improve its outreach. Today, MBPC released its new report looking at some strategies that other states have utilized to expand outreach and enrollment. The report includes specific examples and lessons learned. These lessons come from a number of excellent research reports from the Kaiser Family Foundation, as well as, our direct conversations with individuals engaged in enrollment efforts in Colorado, Indiana, and Washington.

Here are some highlights:

  • Outreach materials are most effective when the information speaks specifically to the personal benefits of having insurance and can be tailored to specific regions or demographics. For example, the state of Washington provided local navigators flexibility in modifying enrollment materials for different regions of the state.
  • Continuous tracking and analysis of enrollment data by region and demographics can help the state better target outreach on an ongoing basis. For example, the Colorado Health Institute conducted a detailed analysis of uninsured levels based on zip code, allowing the state to better target outreach efforts. Colorado targeted rural areas through direct mail cards with details on who qualifies and how to apply.
  • States have also successfully utilized community locations, such as shopping malls, libraries, and schools, to educate the public about affordable health coverage and enroll individuals in Medicaid. The state of Washington set up kiosks at local malls and tied its marketing campaign to the idea of “shopping” for affordable health insurance.
  • States have found other partners that may not be directly tied to health care system to help get the word out. Colorado enrollment assisters engaged for-profit entities, including pizza delivery companies and supermarkets, to include enrollment information during delivery or checkout. Kentucky has utilized community leaders, including faith leaders, to help spread the word of health insurance opportunities.
  • Outreach efforts to inform American Indians of new coverage opportunities in Medicaid must recognize how having health insurance relates to accessing care through IHS, Tribal health clinics, Urban Indian health centers. Outreach efforts should emphasize that American Indians can continue to access care at IHS, tribal, and urban Indian clinics. Gaining access to Medicaid allows clinics to access reimbursements for services through Medicaid, which frees up IHS funds to increase and improve health services for their communities.

We encourage you to take a look at the report, and we look forward to working with our partners across the state to continue to emphasize the success of Medicaid expansion in Montana.

Medicaid Expansion: Enrollment to Date

In just the first few months of new coverage under Medicaid expansion, we are seeing significant enrollment levels and evidence that thousands of Montanans need (and are now receiving) affordable health insurance. This month, the Montana Department of Public Health and Human Services (DPHHS) released new data on the number of people who have enrolled through the Montana Health and Economic Livelihood Partnership (HELP) Act. Since enrollment began on November 2 (with coverage beginning on January 1), over 36,320 Montanans have signed up, exceeding first-year projections on all levels.

This week, we will release a new report analyzing this enrollment and the populations that the state should consider focusing future outreach efforts. The report will also detail a number of successful strategies that other states have deployed to reach eligible families and get them enrolled.

As a preview of this work, here are some of our thoughts so far on enrollment.

Income levels

It is not surprising that Montana has seen a significant portion of newly enrolled individuals at very low incomes. So far, over 60 percent (or approximately 22,000) of those enrolled are living with family incomes below 50 percent of the federal poverty line. For an individual, this represents an annual income of $5,990, or about $490 per month. These are families that, in the past, have had few or no options for affordable coverage. The state and other partner organizations did incredible work to reach these populations using existing data and let them know they would be eligible for new health care coverage options in 2016.

We know that a significant percentage of the uninsured population below 50 percent has now enrolled; future enrollment efforts may be best targeted to populations with incomes between 50 and 138 percent of FPL. This population will be enrolled in the HELP Plan and subject to premiums and copays, so it is critical that the state’s materials are clear on what these premium levels are and the importance of gaining health insurance.

American Indians

While we have seen over 4,300 American Indians enroll, this number is low compared to the estimated percentage of the entire eligible population that is American Indian. According to Census data, American Indians represent nearly 20 percent of the total eligible uninsured population. And yet, only 12 percent of newly enrollees are American Indian.

Outreach efforts focused on eligible American Indians must take into account the unique health care dynamics, including how insurance relates to accessing services through Indian Health Service (IHS), tribal health clinics, and urban Indian health clinics. The state should work closely with tribal leaders and tribal advocates to ensure enrollment is supporting this existing tribal healthcare infrastructure. These types of partnerships are happening across the state, but even more can be done to support health coverage enrollment in Indian country.

Regional differences

We are seeing regional health departments and health centers actively engaged in enrollment efforts across the state, but enrollment numbers show opportunities to expand efforts in certain areas. Over 56 percent of enrollment has occurred in the top five counties in Montana (Cascade, Flathead, Gallatin, Lewis & Clark, Missoula, and Yellowstone counties). And while all five counties are reaching significant numbers of newly eligible, Gallatin County is lagging behind the other counties when comparing enrollment as a percent of eligible uninsured population.

MBPC commends the state, those engaged in Cover Montana, and others involved in enrollment efforts. The need for the HELP Act is clear – with over 36,000 Montanans accessing coverage in just the first couple months.

But thousands more Montanans are eligible. Stay tuned for the release of our report later this week, which will detail our research on strategies that other states have undertaken to reach eligible individuals and get them the health coverage they need.

Open Enrollment Wraps Up, but Medicaid Enrollment Will Continue

The open enrollment period for accessing private insurance on the Marketplace exchange ended last night at midnight. However, those who missed the deadline may qualify for a Special Enrollment Period (SEP) — generally triggered by a change in circumstances, such as:

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  • moving to a new state, or to a place within the same state where different Qualified Health Plans (QHPs) are available;
  • losing other health coverage;
  • gaining or becoming a dependent (e.g., through marriage, birth, adoption, placement for adoption or in foster care, a child support order or other court order);
  • meeting other “exceptional circumstances”.

Montanans should visit the Marketplace website or Covermt.org to see if they qualify for a SEP.

It’s also important to note that there is no deadline for enrolling in Medicaid. To find information on eligible income levels and how to enroll, go to www.covermt.org or http://dphhs.mt.gov/healthcare.

 

Scorecard reveals Montana families’ financial well-being

Have you ever wondered how you can learn more about how Montana families are faring and what types of solutions are available to support them? Today, we’ll look at a comprehensive tool that sheds light on the financial security of Montana families and policies that could help them better make ends meet.

Every year, the Corporation for Enterprise Development (CFED) releases its Assets and Opportunity Scorecard, measuring the economic security of families in each state and highlighting how policies help or hurt their ability to make ends meet.

There are a number of scorecards and studies out there, but we find this scorecard to be one of the most helpful. It not only provides solid data, but also workable solutions that other states have implemented to help strengthen families’ economic security.

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The scorecard is organized into five categories:

  • Financial Assets and Income
  • Businesses and Jobs
  • Housing and Homeownership
  • Health Care
  • Education

New this year is the policy change map, which let’s you see policy gains and losses in each state.

CFED uses two measures – outcomes and policies – to better understand financial security in each state. Overall, Montana ranks 15th in outcomes. These outcomes measure things like rates of poverty, unemployment, and homeownership. CFED also lists policy opportunities to support families. Over the next week, we will dig deeper into some of the data and policy solutions, but here is a quick overview on how Montana fares:

Financial Assets and Income

Nearly one in six households in Montana are living in poverty, and there remains a large gap between high-wage and low-to-moderate wage earners. Over one-fourth of Montana households do not have a savings account.

Enacting a state earned income tax credit (EITC) is one of the best ways to supplement working parents’ income, helping them to catch up on bills, put food on the table, and rise out of poverty. Eliminating asset tests for programs like Temporary Assistance for Needy Families (TANF) help people focus on saving for the future and achieving self-sufficiency. Finally, tax fairness reforms are key to ensuring that corporations and wealthy Montanans are paying their fair share for the things we all need, like schools, police, and roads.

Business and Jobs

For the second year in a row, Montana scores high with small-businesses. However, almost one-in-three jobs are low-wage. Montana workers report that they feel underemployed – many want to work full-time, but are only offered part-time positions – and unemployment rates are twice as high for workers of color.

Enacting paid family and medical leave would help working parents better balance work and home demands by taking time off to attend to their own health needs or that of a family member without risking their financial security. Increasing unemployment benefits so that workers receive an adequate weekly wage while unemployed would help parents afford the basic needs while they search for long-term work opportunities.

Health Care

With Medicaid expansion just recently up and running, it is not surprising that Montana still ranks low on health care outcomes. Montana has already enrolled over 22,000 individuals in affordable health care coverage. We know expansion will have a significant impact on the uninsured rate, and we look forward to seeing how we will compare in 2017.

We encourage you to visit the scorecard. Play around – it’s a lot of fun! And learn more about how Montana families are doing. Also, please follow us this week as we dig deeper into specific policy issues related to the scorecard.

Thank You for a Great 2015

With only two days left in the year, we decided to take a look back and remember what a great year 2015 was.

Together, in 2015, we:

  • Passed Medicaid expansion providing tens of thousands of Montanan access to affordable health care.
  • Defeated dozens of irresponsible tax cuts that would have drained our state of critical resources needed to invest in our communities.
  • Released cutting edge research on paid family leave, tribal colleges, earned income tax credit, and more.
  • Formed two new partnerships with the Women’s Foundation of Montana and the Montana Health Care Foundation.
  • Made real progress toward establishing a Montana earned income tax credit to help working families make ends meet.
  • And much, much more.

It really was a year to be proud of, and we wanted to take a second to say thank you. Whether you wrote a letter to the editor, called your legislator, talked to your friends about Medicaid expansion, donated to MBPC, or simply became more informed by reading our blog, you helped make 2015 one where the lives of our low-income neighbors will be a little bit better.

Unfortunately, 2015 is also the year we say goodbye to our long time staff member, Laura John. Laura has served as the State Tribal Policy Specialist, and her perspective and dedication was critical to our work. We will miss Laura, but we wish her all the best as she begins her next adventure.

MBPC is committed to continuing the groundbreaking work Laura started, and we know she leaves big shoes to fill.

We wish you and your family a fun and safe New Years. We look to next year when we will work on issues like paid family and medical leave, EITC, affordable childcare, pre-Kindergarten, and so much more. Together we can accomplish great things in 2016.

Health Care Reform is Working in Montana and Nationwide

Last Wednesday, the Census Bureau released new data on health insurance rates, showing the benefit of health care reform and growing coverage in states that have expanded Medicaid.

Health care reform is working in Montana. The Affordable Care Act has increased the number of people insured by offering people access to health care coverage through the health insurance marketplace. Through the marketplace, people can easily compare prices and benefits of health care plans. For individuals that make too much to get care through Medicaid but don’t make enough to afford private insurance through the market place, federal subsidies help them pay their premiums and reduce their out-of-pocket health costs. As a result, an additional 22,000 Montanans had health insurance in 2014.

Health care reform has also strengthened Medicaid. The 25 states that have expanded Medicaid to include more people collectively had a higher share of people with insurance than the other 26 that did not expand Medicaid, and that gap is growing. Estimates suggest that if the 26 states had expanded Medicaid, an additional 2.6 million Americans would have gained health insurance last year.

Medicaid is good for people, communities, and states. Medicaid has been improving people’s lives by providing affordable health care that boosts state economies for the last 50 years. Once CMS approves Montana’s waiver, an additional 70,000 residents – who previously couldn’t afford health insurance- will finally have access to quality and cost-effective insurance and a greater share of our state’s population will be insured.

This new health insurance coverage data suggests health reform increases opportunities for affordable and quality health care for millions of Americans. We look forward to an additional 70,000 Montanans receiving health insurance coverage once CMS approves the state’s waiver.

Wonky Word Wednesdays: Tribal Consultation

Today, the state of Montana is holding a tribal consultation, an important requirement in the process to submit its Medicaid expansion waiver to the federal Center on Medicare and Medicaid Services (CMS). But what is a tribal consultation, and why is it important? That brings us to today’s Wonky Word – tribal consultation.

According to CMS, tribal consultation between state Medicaid administrators and tribal leaders and tribal health programs is to “provide an enhanced form of communication that emphasizes trust, respect, and shared responsibility. It is an open and free exchange of information and opinion among parties, which leads to mutual understanding and comprehension. Consultation is integral to a deliberative process that results in effective collaboration and informed decision-making with the ultimate goal of reaching consensus on issues and better outcomes.”

Under federal law, states must engage in tribal consultations when applying for a 1115 waiver. According CMS, tribal consultation requirements are in place to recognize the sovereignty of tribal governments and ensure that any changes to a state’s Medicaid program will not inadvertently create problems for Indian health services. Apart from being required by federal law, this type of discussion is an indication of a state’s effort to support positive and genuine state-tribal relations.

Today, Montana is conducting its tribal consultation in Helena to discuss the soon-to-be-submitted waiver to give tens of thousands of Montanans access to affordable health care. You can view the Department of Health & Human Services invitation to the tribal consultation here.

In the past, states that have failed to properly follow the tribal consultation requirements have been met with disapproval either from CMS or from tribal leaders and their advocates. It is important for states to know that inadequate consultation could potentially hinder a state’s waiver approval. An example of this consequence include a letter from the New Mexico Center on Law and Poverty about the lack of tribal consultation resulting in the CMS rejection of New Mexico’s waiver application. Similar circumstances have occurred in Kansas and Oklahoma.

In 2013, CMS released a report on tribal consultation best practices, which included formal tribal health consultation policy examples from Washington, Oregon, and Minnesota. Here is the report summary of successes and challenges:

Respondents noted various attributes that contribute to the success of these interactions, including: Involvement and support of tribal and state leadership, an established state-tribe relationship, and genuine, meaningful, and open communication. In contrast, barriers to effective consultation reflected issues such as: obstacles created by consultation requirements, state or tribal staff turnover, and resource limitations preventing participation in consultations.

You can view the entire CMS Tribal Consultation Best Practices report here.

Tribal consultations are important government-to-government discussions that help ensure the proposed state policy takes into account tribal sovereignty and the strengths and needs of Indian Country. We look forward to hearing from the tribes and the state on how today’s consultation will make Montana’s waiver even better.