Wonky Word: Essential Health Benefits 

During recent weeks, you have probably heard the term Essential Health Benefits repeatedly as Congress continue efforts to repeal and replace the Affordable Care Act (ACA). Right now, the Senate GOP leadership is cooking up their version of a health care bill behind closed doors and could take a vote before the July 4th recess.

The House-passed GOP plan eliminates Medicaid expansion and dramatically cuts Medicaid funding. Congress is also considering measures to allow states to waive the essential health benefit rules within the ACA. What are “Essential Health Benefits” and why have they become so central in the debate around health insurance coverage in America?

Essential Health Benefits (EHBs), also called federal minimum benefit standards, are at heart of the ACA. EHBs outline a set of ten categories of services that health insurance plans must cover at minimum. States must also provide EHB to beneficiaries eligible under the ACA’s Medicaid expansion, and plans may offer additional benefits such as dental and vision coverage.

Prior to the ACA, it was up to each respective state to determine what benefits (called insurance mandates) had to be included in insurance plans. Not surprisingly, states differed widely in terms comprehensiveness required, and no specific benefit was deemed essential in all 50 states and Washington, D.C.

EHBs provide coverage that offers viable protection against some of the most basic health care costs Americans experience and were designed to provide marketplace consumers with insurance coverage similar to the coverage of employer-sponsored insurance and Medicaid.

So, every health plan must cover the following services1: 

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
  • And these two additional benefits:
    • Birth control coverage (contraceptive methods and counseling for all women)
    • Breastfeeding coverage (breastfeeding equipment and counseling for pregnant and nursing women)

Before the ACA, most health insurance frequently did not cover these basic services. For example, in 2011, among people in the individual market:

  • 62 percent had plans that didn’t cover maternity care;
  • 34 percent had plans that didn’t cover substance use treatment;
  • 18 percent had plans that didn’t cover mental health; and
  • 9 percent had plans that didn’t cover prescription drugs.

Under the GOP’s replacement plan, comprehensive insurance, with benefits like maternity or mental-health coverage, could become unaffordable—if not unavailable.

If the Essential Health Benefit standards were eliminated, individual and small-group market plans would quickly revert to the pre-ACA status quo and would likely:

  • Leave people who have pre-existing conditions without the coverage they need. People with pre-existing conditions — who need services like substance abuse treatment,mental health services, or comprehensive prescription drug coverage — often wouldn’t be able to find the coverage they need at any price, much less an affordable one.
  • Charge women more than men for coverage. In practice, eliminating Essential Health Benefit requirements means that women would once again be charged more than men, since they’d have to pay more for plans with maternity coverage — if they could even find a plan.
  • Burden even insured people with unaffordable bills and medical bankruptcies. Before the ACA, millions of people had health insurance that wouldn’t actually cover them if they got sick. Plans often had annual and lifetime limits on coverage and no limits on individuals’ out-of-pocket costs, and they omitted key services.The ACA fixed this by prohibiting annual and lifetime limits and setting an annual limit on what enrollees can be required to pay out-of-pocket for deductibles and other cost-sharing. Eliminating the Essential Health Benefit standards would make these rules meaningless.

SNAP Improves Outcomes for Montana’s Kids

Elizabeth The Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) helps Montana families put food on the table and make ends meet. But we also know that it accomplishes much more than that. SNAP is actively improving our children’s futures.

Research increasingly shows that SNAP can protect children against the long-term effects of experiencing poverty and food insecurity, events that take a toll not only on immediate well-being but can impact children’s economic and social mobility into adulthood. Nearly 20% of Montana’s kids live in poverty and just over 18% live in food insecure households, putting them at risk of poorer health outcomes, reduced nutrition, lower academic achievement, and increased behavioral issues.

Hungry kids often have trouble focusing, which makes it hard for them to pay attention at school and retain information. And parents who are too busy worrying about where their next meal will come from don’t have enough time or energy to focus on their child’s education. Studies show that young children whose families qualify for and receive SNAP are at lower risk of developmental delays than children from similar low-income families who do not receive food assistance from SNAP.

SNAP helps form a strong foundation of health and well-being for low-income children by lifting millions of families out of poverty, improving food security, and helping improve health and academic achievement. SNAP delivers more nutrition assistance to low-income children than any other program. In Montana, SNAP helps about 48,700 children each month, or more than 1 in 5 of our state’s kids.

In addition, more Farmer’s Markets are accepting SNAP, which helps families to access fresh, local produce and ensures their kids have the right nutrition to thrive. In Montana, SNAP is accepted at 23 Farmer’s Markets, a growing number of which also offer ‘double SNAP dollars’, an incentive program that doubles the dollar amount SNAP customers can spend on fresh produce.

SNAP is helping to give thousands of Montana children the foundation they need to succeed and the fuel they need to thrive. Efforts to reform or enhance the Supplemental Nutrition Assistance Program should build on its effectiveness in protecting the well-being of our children, and preserve the essential program features that contribute to that success.

Elizabeth Weaver, SNAP Outreach Coordinator, Montana Food Bank Network

Myth Busting: What is really at stake with Medicaid and AHCA

Last week there were two articles quoting Senator Daines on health care and the continued effort in the Senate to repeal and replace the Affordable Care Act: Senator Daines Urged To Protect Medicaid and Daines and Tester weigh in on status of ‘Obamacare’ repeal in U.S. Senate. Some of the statements made about Medicaid were inaccurate, and we want to provide additional context on how Medicaid works and its importance to accessing health services in Montana.

MYTH #1: The original Medicaid program focused on those in deep poverty and seniors below the age of 65.

FACT: In fact, before passage of ACA, Medicaid left out many low-income individuals, including most seniors living in poverty. Montana’s bipartisan Medicaid expansion provides health coverage to those exact populations.

Before the Affordable Care Act and Montana passed Medicaid expansion, Medicaid did not cover the very poor unless they were disabled or had children under the age of 18-years-old. This left tens of thousands of Montanans below the poverty line uninsured. Additionally, Medicaid did not take care of older adults who were under 65 unless they qualified due to a disability, meaning that low-income seniors between 50-64 often did not qualify for Medicaid.

Montana’s bipartisan Medicaid Expansion plan has provided access to health care coverage to nearly 80,000 low-income Montanans, including seniors, adults, and others.

 

MYTH #2: Congress should give states more flexibility to administer their Medicaid programs.

FACT: States already have significant flexibility in how they run their Medicaid program, and cuts to federal Medicaid funding will only make it harder for states to provide access to coverage and benefits.

In exchange for the federal funds, states must meet federal standards that reflect the program’s role covering a low-income population with limited resources and often complex health needs. The federal standards largely focus on requiring states to cover certain groups, such as poor children and pregnant women, as well as certain core benefits.

However, states can choose to cover additional groups, offer enhanced benefits, and already have wide latitude over many aspects of the program, particularly how they pay providers and structure their delivery systems. States can use Section 1115 waiver authority to vary from the federal standards and state options to address different priorities and emerging issues.

The programs across states vary widely in terms of who is eligible, what benefits are covered, what premiums and cost sharing are charged, and how providers are paid and care is delivered.

 

MYTH #3: Medicaid expansion can be protected if the phase out of the higher federal match occurs over several years.

FACT: Any phase-out of the higher federal match for Medicaid expansion will end Medicaid expansion in Montana.

The House-passed AHCA eliminates the higher match of federal funds for those who would be newly enrolled after 2019. The Senate is considering a longer phase-out, but to be clear: this has the same effect. CBO estimates that more than two-thirds of those enrolled in the Medicaid expansion would fall off the program within two years and that fewer than 5 percent would remain on Medicaid after six years. For those who see their income drop after phase out, the state would not receive the higher match and would most likely no longer be able to afford to continue to provide Medicaid to this population.

 

MYTH #4: Medicaid creates a disincentive to individuals to seek employment or employment opportunities with higher wages.

FACT: Among adults with Medicaid coverage—those most likely to be in the workforce—nearly 8 in 10 live in working families, and a majority are working themselves.

Nearly half of working Medicaid enrollees are employed by small businesses, and many work in low-wage industries that do not offer employer-paid insurance. Since the majority of Medicaid expansion enrollees are low-wage workers, Medicaid expansion prevents them from falling into the coverage gap; it helps them cope with high turnover in the low-wage labor market.

Medicaid expansion and the tax credits and subsidies under ACA provide a smoother transition to private Marketplace coverage. This has been particularly important for Montanans living in rural communities, accessing Medicaid and insurance on the marketplace at a greater rate. When their earnings rise or they get a new job, they can transition to employer coverage or the ACA marketplaces. Under ACA, the tax credits and subsidies provide significant support to lower costs for marketplace coverage. And families have the security of knowing that Medicaid will be there for them again if they lose their job, see their hours cut, or face financial crisis. Additionally, when they no longer qualify for Medicaid but live at 139% of the poverty rate, individuals can currently qualify for a tax subsidy to help pay the health insurance premium.

By eliminating Medicaid expansion and cutting tax credits for low-income families, the AHCA (and likely any iteration from the Senate) will create a situation where many families may have to choose between employment and keeping health insurance. For example, a family who earns $20,000 in Montana will see their premium paid after tax credit rise by 295% for a total of $3,690. That is the equivalent of 15% of that family’s income.

Mother’s Day: What Moms need is health care

We hope moms and moms-to-be around the state had a wonderful Mother’s Day.

Because we love our moms and we are a female-led organization, our team spent time looking into how the House GOP bill to repeal and replace the Affordable Care Act (ACA) might affect women, and moms specifically.

The ACA changed the landscape for women’s health insurance coverage. As we await the Senate’s version of a bill, it is crucial to understand the particular damage that ACA repeal poses for women’s health and economic security.

We know that much attention has been given to the provision of the AHCA that allows states to waive the “essential health benefits” coverage for individual market plans. Which basically means that pregnancy, c-sections, or injuries from domestic violence are included as pre-existing conditions and subject moms and women to significantly higher premiums.

However the issue of fundamentally changing Medicaid is equally as detrimental to moms in our state and country. As it stands, the House health bill would have devastating consequences for the nearly 40 million women across the country who rely on Medicaid. In Montana, 129,200 women are enrolled in Medicaid and 35% of births are financed by Medicaid.

The House-passed bill would slash Medicaid by more than $800 billion over ten years by effectively eliminating Medicaid expansion to low-income adults and imposing a “per capita cap” on the program.

Women would bear a disproportionate impact of these cuts because they are not only the majority of Medicaid beneficiaries, but are also the primary utilizers of family planning and maternity care, benefits that could be eliminated with devastating federal cuts to Medicaid.

In addition, Medicaid expansion gave many women not raising children access to coverage and offered continuous coverage to new mothers who had qualified while pregnant but would not have qualified after their pregnancy. Ending the expansion would take these benefits away.

There are a few other benefits the ACA gave women that could be lost with repeal. One is breastfeeding. The ACA covers lactation support and counseling, equipment and supplies, such as pumps, and infrastructure, such as pump rooms and break time. The other is access to birth control which provides health benefits for women and children, improves women’s ability to control whether and when they have a child, and fosters women’s ability to participate in education and the workforce on an equal footing with men. The ACA was a total game-changer when it comes to access to birth control for women because it removed the cost barriers. Women no longer have to pay out-of-pocket costs or choose between paying for birth control and paying for other necessities, like groceries and utilities.

The ACA and Medicaid have been hugely beneficial for women’s health. With the potential repeal hanging above us, women – and mom’s – have a lot to lose. While the future is uncertain, we want to make sure that women and moms continue to have access to affordable health care. We encourage all moms, women, and the men in their lives to contact our Montana Senators and tell them to reject any health bill that causes people to lose coverage, caps or cuts Medicaid, ends the Medicaid expansion, or takes away critical protections.

Wonky Word: Healthy Montana Kids & CHIP

This week is Children’s Mental Health Week and today is National School Nurse Day. So we thought today would be a great day to recap CHIP and the Healthy Montana Kids (HMK) for our wonky words this week.

In 1997, the federal government established the Children’s Health Insurance Program (CHIP). The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. CHIP provides health coverage to eligible children, through both Medicaid and separate CHIP programs. It is administered by states and funded jointly by states and the federal government. Since states have flexibility to design their own program within Federal guidelines, benefits vary by state. Unfortunately, in the late ‘90s, there was a waiting list for children who were eligible but not enough funding.

Then in 2008, a group submitted a ballot initiative – Healthy Montana Kids I-155 – to the voters. The idea was to expand CHIP by using premium taxes paid by insurance companies to make health insurance available to more children. It raised the ceiling of eligibility to families earning up to 250% of the federal poverty level (FPL) (what is now approximately $51,000 for a family of three) with the goal of covering an additional 30,000 children. The initiative passed in all 56 counties and received 70% of the statewide vote.

Shortly thereafter, the 2009 Montana Legislature enacted the Healthy Montana Kids program. It brings CHIP and Children’s Medicaid under one umbrella with only one application process. Children below 143% of the FPL qualify for Medicaid and children between 143%-261% qualify for CHIP.

What makes HMK so unique – and what makes the Healthy Montana Plan unique – is that it competitively contracts with an insurer to administer healthcare through a private provider network at negotiated rates. This kind of contract is known as a “third party administrator,” or TPA. The TPA for HMK is Blue Cross Blue Shield of Montana and this contract grants access to care through the contractor’s extensive provider network. The contractor processes the claims and issues fee payments to providers on behalf of the state. Montana reimburses the contractor for those claims on a fee-for-service basis.

Healthy Montana Kids covers more than 120,000 children in our state. This means regular check ups, dental care, vision, and help when there is an emergency. The Medicaid Access and CHIP Reauthorization Act (MACRA) extended CHIP funding with no programmatic changes through September 30, 2017. That means legislative action will be required to extend federal funding past September, which is just 4 months away. When we talk about health care, we need to make sure we talk about CHIP reauthorization too. Kids with coverage help keep medical costs down for all of us, and kids with coverage are healthier. Healthier kids mean they do better in school, which will lead to a more educated work force.

The New House Health Care Plan Makes a Bad Bill Even Worse

While Montana still is without a congressional representative, the House is poised to vote on a bill tomorrow, which could result in 259,000 Montanans either losing their coverage or facing increased out-of-pocket costs for health insurance.

Press reports have indicated House leadership continues to try to cobble together votes to repeal ACA, and we could see a vote on a newer version of the GOP plan as early as tomorrow or Saturday. The revised version does nothing to address the 24 million Americans who will lose coverage or the cut of over $800 billion in federal Medicaid dollars. Instead, the amended GOP plan makes a bad bill even worse, in three ways:

  • Gutting protections for Montanans with pre-existing conditions: The new proposal would allow states to eliminate protections for those with pre-existing condition. Insurance companies would now have the power to deny coverage based on pre-existing conditions except in states that choose to prohibit it. 426,400 Montanans have pre-existing conditions and risk losing the coverage they desperately need.
  • Eliminating coverage for services, like maternity care, mental and substance use treatment, and prescription drugs: The new version of the GOP plan would also allow states to waive Essential Health Benefits standards that require plans to cover services such as mental health and substance use treatment. It would also do away with guaranteed maternity care coverage, effectively allowing plans to charge women more for insurance than men.
  • Reinstate annual and lifetime limits on health care: The ACA prohibits plans from limits on coverage that are Essential Health Benefits. If states are allowed to eliminate the Essential Health Benefit standards, plans could likely place caps on coverage for those services, such as emergency services, impatient care, and prescription drugs. Before ACA, over 330,000 Montanans – most with employer coverage – faced lifetime limits on health services. The new, worse GOP plan could put in place these same practices, which means even those Montanans who can afford coverage could be one major illness away from bankruptcy.

This new bill is in no way a compromise or an improvement. Instead, it only further exacerbates the problems it would create for millions of Americans. This flawed proposal would: shift of over $3 billion in Medicaid costs to the state, end Montana’s bipartisan plan to expand Medicaid covering over 71,000 Montanans, and raise premiums and health care costs on tens of thousands of Montana families. D.C. politicians must take note – the GOP plan is a dangerous move that is wrong for Montana.

 

Indian Country Suicide Prevention Receives Attention and Investment

Maybe it’s our relative isolation and inability to easily access sufficient mental and behavior healthcare. Or maybe it’s the elevation or the sigma we often associate with depression. Whatever the reason, Montana has had one of the highest suicide rates in the country for almost forty years.

According to a report by the Montana Department of Health and Human Services, Montana ranked first in the nation for suicides in 2014. Nationally, whites have the highest rate of suicide, followed by American Indians. In Montana, this trend is reversed. Between 2014 and 2015, the American Indian suicide rate was 35.5 (per 100,000 people) compared to 28.1 for whites.

The same report notes that American Indian youth ages 11-17 are especially at risk. In fact, they are almost four times more likely to die by suicide than their white counterparts in Montana. Further, youth suicidal risk assessments for 2015 also show that American Indian youth living in urban areas are more likely than reservation-residing American Indian youth to seriously consider, plan, and attempt suicide.

We know that suicide has been a major public health concern in Montana for years, and particularly in Indian Country. This is why we applaud the legislature’s recent passage of House Bill 118, which invests $1 million in statewide suicide prevention efforts. Of this, $250,000 goes expressly to implement the action steps outlined in the Montana Native Youth Suicide Reduction Plan (MNYSRP). The Indian-owned consulting firm, Kauffman & Associates, in collaboration with both reservation and urban-based tribal communities in Montana, as well as the five urban Indian Health organizations created MNYSRP. MNYSRP came about as a result of an initiative developed by Governor Bullock in 2015, which was funded through the 64th Montana Legislative session.

An official bill signing has been scheduled for Tuesday, April 25, 2017 at 3pm.

Montana Budget Not Ready for Prime-Time

With less than two weeks remaining in the legislative session, the state budget is far from ready for the governor’s signature. Last week, legislative fiscal division released its updated status sheet. Factoring in the current spending bills, tax bills, current revenue estimate, and the budget, the legislature is leaving the state with a mere $162 million in projected ending fund balance. That current level is $138 million below the long-standing precedent for a $300 million ending fund balance. Perhaps even more shocking, it’s $38 million below some Republicans’ counter-proposal for a much lower $200 million ending fund balance.

Thus far, the legislature has:

  • Failed to support nearly all of the governor’s tax fairness measures that would raise needed general fund revenue and provide a pathway for a balanced solution to the recent revenue downturn;
  • Left significant cuts to the budget, particularly in the areas of higher education and social service programs for our seniors and Montanans with disabilities;
  • Passed a myriad of new spending bills that risk leaving an insufficient ending fund balance for dealing with an economic downturn or lower-than-expected revenues; and
  • Increased the revenue estimate simply as a mechanism for balancing the budget.

Any one of these problems should cause concern for the governor and any Montanans who care about the budget and the essential services it funds. The combination of the current problems is simply unacceptable and unsustainable.

The legislature has so far failed to make the difficult choices necessary for a responsible budget. As has been true all session, they have two choices: make further cuts to the budget and other spending priorities or raise revenue. MBPC believes only one responsible choice remains: raising revenue. With significant cuts already proposed by the governor and deeper cuts adopted by the legislature, the legislature must, finally, engage in a meaningful conversation about sensible ways to raise revenue. Options include listening to the dozens of health care professionals and organizations who have asked for an increase in the tobacco tax (which not only raises revenue but also is proven to reduce smoking and decrease health costs) or making sure that millionaires in Montana are paying their fair share for the services and infrastructure that make our families and communities stronger.

It may be that legislators are planning to force the governor to make the additional cuts to popular and essential programs. The governor did his job in proposing a responsible budget, one that included both difficult budgetary cuts but also adequate levels of revenue. Legislators were elected to make the same kinds of hard decisions. If they are going to reject every general fund revenue increase, they need to find other solutions for putting a responsible budget on the governor’s desk.

Equal Pay Day and EITC

Now that spring is in the air, 2016 seems like a long time ago. But it took until today – April 4th – for women to finally earn as much money as a man did in 2016. With such a significant pay disparity between men and women, women have to work three months longer into the next year to make the same amount that men make in a single year.

In Montana, women still are paid only about 67 cents for every dollar a man earns in spite of the fact that more women than ever are the primary breadwinner. In about 40 percent of U.S. households with children under age 18, mothers are the sole or primary breadwinner. For female-headed households, it hurts a lot more when women aren’t paid fairly.

The good news is that a state Earned Income Tax Credit (EITC) could help boost the pay of thousands of low income women. The legislature is considering HB391, which would create a state version of the federal EITC, a tax credit paid to working adults. The Center on Budget and Policy Priorities estimates that 22,000 single mothers in Montana would benefit from receiving the EITC.*

But the EITC does far more than just provide a little extra cash for families. Studies show that the EITC has encouraged large numbers of single mothers to increase the amount of hours they work, and reduce their reliance on social safety net programs. In turn, this increase in hours worked leads to higher wage growth down the road, as well as greater Social Security retirement benefits. The EITC’s impact on employment actually doubles the anti-poverty effect of the EITC for families.

Furthermore, the benefits of the EITC for women aren’t purely financial. Research has also shown that it reduces the rate of low-weight and premature births and improves the health indicators of the mothers. In these studies, women who have received increases in their EITC were more likely to receive prenatal care.

For thousands of workers in Montana, a state EITC could have significant impacts for parents and children alike. In total, 80,000 low- and moderate-income families in Montana stand to benefit from this credit. But for 22,000 single mothers, the EITC can provide additional important benefits that will help improve the stability and health of the entire family.

All hard-working Montana families should get the pay they deserve. While we may have a long way to go in order to minimize the disparity in pay between men and women, a state EITC can be a positive step to reduce the harm this gap causes. Our state legislators should enact a state EITC and improve the lives of thousands of working mothers and their children.

 

* CBPP estimates based on data from IRS, unpublished data from the Brookings Metropolitan Policy Program, and CBPP analysis of the Census Bureau’s March 2010-March 2014 Current Population Survey

A Budget Built on a House of Cards?

Today, the legislative fiscal division (LFD) released its weekly general fund status sheet, providing us a glimpse at where we stand with general fund revenue, projected spending, and the resulting ending fund balance. As the legislature takes actions on bills, including HB 2, LFD updates the status sheet to reflect these changes in spending and revenue bills.

This past week, the Senate Finance & Claims Committee took action on HB 2, adding back some of the cuts made in the House. In total, the Committee restored about $10 million in general funds, $32 million in state special revenue, and $12 million in federal funds.

The status sheet answers a big question: is restoration of these cuts sustainable under the current levels of revenue? The answer: no.

As of today, legislative fiscal division estimates an ending fund balance of $154 million at the end of the next biennium. The status sheets factors in SB 354 to raise the tobacco tax, which passed the Senate this week. This measure raises nearly $69 million in general fund revenue, but still needs to pass the House to become a reality. Even factoring passage of SB 354, we are $145 million below the Governor’s requirement of a $300 million ending fund balance. The ending fund balance is important because it is Montana’s only mechanism for protecting against revenue volatility and unexpected emergencies. This is Montana’s savings account.

Those who have been worried about the budget cuts – including cuts to Medicaid services for seniors and people with disabilities, cuts in higher education, and cuts to programs essential for our emergency responders in local communities – still have work to do. Higher education still faces over $11 million in cuts. Just as importantly, the budget still has several important stages to go and cuts can still be reinstated or increased. As it stands now, the budget is built on a house of cards that could collapse at any moment. We need to continue to be diligent in urging policymakers to pass new revenue and update the revenue estimate, to ensure adequate resources to fund programs essential to our communities.

Want to know more about actions taken this past week on the budget? Check out our quick summary here.