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Medicaid

A county’s difficult question: How to save its local hospital?

Elbert Memorial Hospital needs funding from the county in order to remain open.

Elbert Memorial Hospital needs funding from the county in order to remain open.

Elbert Memorial Hospital has served its northeast Georgia county for more than 60 years.

But the future of the hospital is now unclear. Its fate will hinge on the coming days and weeks.

Elbert County commissioners are holding public hearings this week and next on a proposed one-mill property tax increase for one year to raise about $500,000 to offset the Elberton hospital’s costs for indigent care.

Without the money, the 52-bed hospital will close, officials warn. That would eliminate more than 200 jobs, and residents would have to travel more than 30 miles to the nearest hospital. A closure would jolt the mostly rural county’s economy.

Elbert Memorial lost $1.5 million in its last fiscal year, CEO Jim Yarborough said Tuesday. “Our concern is that charity care and bad debt are trending upward,” he said. Yarborough calls the financial crunch facing many Georgia hospitals “a silent epidemic.”

The hospital’s predicament demonstrates how counties and hospitals depend on each other financially, and how revenue pressure on each is creating an unprecedented squeeze.

“Counties are in major turmoil deciding whether they want a hospital or pick up the garbage,’’ said Jimmy Lewis, CEO of HomeTown Health, an organization of rural hospitals in the state. Meanwhile, he added, “The general cash position in most rural hospitals is extremely dire.’’

Hospitals are facing lower reimbursements from government programs and private health insurers, along with high levels of uninsured and underinsured patients.

But another key issue is Georgia’s decision not to expand Medicaid, hospital execs say.

Gov. Nathan Deal and Georgia’s legislative leaders, citing costs, have decided not to expand Medicaid as outlined under the Affordable Care Act.

Expansion “would help significantly,’’ Yarborough said. “It would create a paying source” from uninsured low-income patients, he added.

The Elbert County predicament comes in the wake of five hospitals closing in Georgia in the past two years. Four were in rural areas. And several other hospitals around the state are struggling just to stay open.

Debra Nesbit

Debra Nesbit

“If this disturbing trend continues, we’ll have major access-to-care issues for hundreds of thousands of Georgians throughout the state,” Kevin Bloye of the Georgia Hospital Association told GHN recently. “It will also have devastating financial consequences to areas that lose their local hospital which serves as a major economic engine.”

Meanwhile, hospitals’ requests to counties for help are more urgent now, said Debra Nesbit of ACCG, which represents county governments in Georgia. “The counties are really struggling with that.”

“Hospitals are saying, ‘Give us money or we are going to shut the door,’ ’’ Nesbit added. But with property appraisals decreasing, she said, counties have financial problems of their own. “They may not have the resources, particularly in rural areas.”

Most counties are supporting their hospitals financially, Lewis said.

Reimbursement reductions for hospitals “translate into an unfunded mandate onto the county,” Lewis added. “Rural unemployment rates are so high there’s no millage capacity to support the unfunded mandate.”

Some counties are pursuing new avenues to keep their hospitals upright. Recently, Habersham County in the northeast Georgia mountains agreed in a deal with the
local hospital authority to make monthly bond payments on Habersham Medical Center’s $37 million debt. The county will eventually take over the assets of the facility.

Newton Medical Center

Newton Medical Center

In Newton County, east of Atlanta, 97-bed Newton Medical Center recently requested a property tax increase to offset indigent care costs. It would have resulted in about a $600,000 funding increase, said Troy Brooks, assistant administrator of fiscal services for the hospital. But he said the county has already set the budget and did not include the funding that the hospital requested.

The hospital isn’t in danger of closing, Brooks indicated. Last year the hospital posted its first positive margin since fiscal 2008, which Brooks attributed to the nearly $2 million in funds related to the Electronic Health Record initiative in the Affordable Care Act.

 

Rocky times in the rock hills

 

Elbert County takes pride in its granite industry, and Elberton calls itself “The Granite Capital of the World.”

But its overall economy is less solid.

About one in four residents has no health insurance, according to the 2014 County Health Rankings, produced by the Robert Wood Johnson Foundation and the University of Wisconsin. The report also shows the Elbert County unemployment rate is higher than the state average, and that about one in three children live in poverty.

Elbert County

Elbert County

As the Elbert County commissioners hold public hearings on the tax increase, Elbert Memorial’s website sums up the situation: “This financial relief is needed to keep our hospital from closing, which would result in a devastating economic loss to the community and leave Elbert County residents without local access to health care services.”

Yarborough said he’s “very hopeful and optimistic” about the financial help. Still, he noted that in the current hard times, “there is a portion of citizens that are not in favor of a property tax increase.”

Elbert Memorial has an affiliation and management agreement with AnMed Health in nearby South Carolina, which has helped the hospital. Nevertheless, the charity care and bad debt for Elbert Memorial Hospital grew to nearly $4 million in its last fiscal year.

The request to the county commissioners is for funding the charity care of Elbert County residents. “They don’t have a mechanism to pay,” Yarborough said. “The ER always has to take care of you.”

The county commissioners will take a final vote on the tax increase after the public hearings. Commission Chairman Tommy Lyon said if the hospital closes, the county will have to add another ambulance and crew to transport patients to hospitals in Athens or in Anderson, S.C. – a step that would cause the budget to be in deficit.

“We’re in a very dire situation,’’ Lyon said, according to an Elberton Star article.

A recent report by the Urban Institute said Georgia’s decision not to expand Medicaid will cost the state’s hospitals $12.8 billion in lost reimbursements over a 10-year period. Medicaid expansion – making more low-income people eligible for the program – would ensure some reimbursement for hospitals that treat these people.

Hospital executives aren’t saying expansion is a complete cure-all. In Georgia, said Yarborough, Medicaid pays only 85 percent of the cost of a covered patient’s medical services. “We lose 15 cents on every dollar,’’ he said.

Still, Yarborough noted that for a hospital, getting “85 cents on the dollar is much better than zero cents on the dollar.”

Brooks of Newton Medical Center said, “I am hearing that hospitals in those states that did expand Medicaid have seen noticeable improvement because of it.”

Nesbit of ACCG recognizes the political realities in Georgia. “Clearly, Medicaid expansion is off the table right now,” she said.

“We don’t have a position on Medicaid expansion,” Nesbit said, though she added, “We want all Georgians to have access to health care.”

“We are continuing to look at the situation, look at creative ways to expand some health care access.”

Elberton Georgia, Granite Capitol

Elberton, in northeast Georgia, takes pride in its famous granite industry.

A health care Q&A with Gov. Deal

Gov. Nathan Deal visits WellStar Cobb Hospital in Austell last year. Photo courtesy of Andrea Briscoe

Gov. Nathan Deal visits WellStar Cobb Hospital last year. Photo courtesy of Andrea Briscoe

Nathan Deal has been involved in many high-profile decisions on health care while serving as Georgia’s governor.

Deal, who is running for re-election this year, has staked out his opposition to the Affordable Care Act (often called Obamacare) and to expanding the state’s Medicaid program. He has also supported changes to the health plan covering state employees and educators, following a wave of criticism that occurred after a new benefits framework debuted Jan. 1.

Georgia Health News recently emailed questions to Deal on a wide range of  major health care issues in the state. We received his reply Monday,  shortly before the scheduled close of the 2014 General Assembly.

In his answers, he discusses pending legislation, the federal law on ER care, the financial struggles of rural hospitals, and what he sees as ways the state can improve its health care system.

Here are GHN’s questions and Gov. Deal’s responses:

 

Q: What is your biggest accomplishment as governor in the field of health care?

A: When Washington tried to levy the huge taxpayer burden that is the Affordable Care Act on Georgians, I could not allow for billions of dollars of our state budget to be diverted from our schools and our citizens. By mitigating that disastrous impact on our state — an additional 620,000 people on Medicaid rolls and billions of dollars — we are keeping our budget balanced and protecting the people of Georgia.

Q:  As governor, you have blocked Medicaid expansion in Georgia. House Bill 990 would require legislative approval for any such expansion in the state. Do you support this legislation?

A: Yes, just the expansion of Medicaid would cost Georgia an additional $2.5 billion over 10 years. This will have major budgetary impacts so it only makes sense to have our state legislature play a part in the decision making process.

Q:  Do you foresee any circumstances under which you would support an expansion of Medicaid?

Gov. Nathan Deal

Gov. Nathan Deal

A: No, not under current conditions. I am doing everything in my power to rebuild our school funding as we come out of the Great Recession. We simply cannot afford the $2.5 billion in new spending that the expansion would require without a severe impact on public education. The federal administration needs to start acknowledging the Supreme Court ruling and look at other alternatives that don’t force new spending by the state. I have often discussed the advantages of a block grant. States need more flexibility in order to make their program work for their unique population rather than a one-size-fits-all Washington mandate. When I was a congressman, I served as chairman of the health subcommittee of Energy and Commerce. The need for flexibility is not new to me, but serving in my role as governor has only reinforced the notion that states can operate more efficiently with flexibility.
Q: HB 707 would prohibit employees of any state unit from spending state funds to advocate for Medicaid expansion. It would also bar the University of Georgia from operating its current navigator program, which hires and trains people to help consumers use the health care exchange. Do you support this legislation?

A: It is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: You recently commented that changes to the federal EMTALA law (requiring hospitals to treat arriving ER patients) can help reduce health care costs. Can you expand on those comments?

A: I have always been a supporter of promoting primary care and preventative care as opposed to emergency room visits for non-emergency circumstances. In the case of a true medical emergency, people should always have access to emergency rooms. However, for non-emergency situations, we should encourage those people to seek treatment in a more cost-effective setting, thus opening beds and reserving resources for those in most critical need. Because there is some confusion on this issue, let me be clear: No one’s going to be denied service. None. This isn’t about blocking doors to health services. It’s about opening new doors that yield better health outcomes at a fraction of the price of emergency rooms. The onus is on us to make sure these non-emergency resources are available and convenient to the populations in need of service.
Q: Four rural hospitals have closed in Georgia over the past two years. Can the state of Georgia do anything to prevent more from closing?

A: I recognize the critical need for hospital infrastructure in rural Georgia, as they save lives and maintain our communities. Hospitals large and small have all felt the impact of the recent economic downturn. While support that these hospitals received has diminished, I am hopeful that as the economy improves, so does the flow of funding and contributions that keep our rural areas thriving. We will continue to monitor the situation with the Department of Community Health.

Q: The changes to the State Health Benefit Plan that began in January have sparked a wave of criticism from educators, state employees and retirees. Will the pending switch to a co-pay system alleviate the members’ concerns?

A: The intention of those changes was to lower out-of-pocket health care costs for state employees. The SHBP already covered 100 percent of preventative care visits, and these improvements give employees an additional layer of security so they can do the right things to stay healthy. I believe the changes address the core concerns of our employees, but the Department of Community Health will continue to monitor and evaluate the situation.

Q: Medical marijuana has suddenly become a high-profile topic in the General Assembly. Do you support this legislation that would create a mechanism to help children with seizure disorders?

A: As I said previously, it is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: What can be done to improve the health care system in Georgia?

A:  Since taking office, I have focused on the need for additional health professionals in Georgia. We have been increasing the number of residency slots in hospitals across the state. Georgia taxpayers help fund a promising young Georgian’s pre-K, K-12, post-secondary and graduate-level medical education only to see them perform their residency outside of our state and not return. That doesn’t provide value for Georgians paying taxes. It doesn’t make sense for Georgians needing care and it isn’t fair to young Georgians looking to begin medical careers. We must ensure that no doctor trained in Georgia is forced to leave the state to complete his or her medical education. There is still work to be done, but we are making strides on this front. Individuals in Georgia can also play a major role in improving their own health by being active in their healthcare decisions. This means taking advantage of all the preventative care opportunities to improve the well-being of themselves and their families.

 

 

 

 

Carter: ‘Reduce the size of our uninsured population’

State Sen. Jason Carter (D-Decatur) recently announced that he is running to become governor of Georgia, attempting to follow in the footsteps of his grandfather Jimmy Carter, who was governor of the state from 1971 to 1975. 

Carter sat down this week with GHN to discuss a range of health care issues, including the Affordable Care Act, the criticism of the State Health Benefit Plan, and the financial struggles of rural hospitals.

 (GHN is also reaching out to Gov. Nathan Deal for a similar interview on health care topics.)

 Here is the Carter interview:

 

IMG_4884

Q: What are your thoughts about House Bill 990, which would require legislative approval for any expansion of Medicaid in Georgia?

A: I think it’s essentially a political bill. If you examine the bill by looking at the problem that it’s attempting to solve, it’s very difficult to discern what the Legislature believes that problem to be, other than they’re worried that I’m going to get elected governor . . .

The politics are real and I think are at the forefront of it. I think the thing that’s amazing to me is that the governor would agree to give up the ability to respond in an appropriate way to the situation that’s there, to operate the state government as an executive. And I think that’s part of a pattern that this governor’s leadership style has been essentially one of passing the buck on important issues. And I think that’s a problem. This bill is indicative of that pattern.

Q: You’re in favor of Medicaid expansion?

A: What I believe is that we have to look at this problem critically. I think expansion should be on the table … and make sure those folks [eligible for coverage] can get either private insurance on the exchanges or get a Medicaid-like expansion — it all has to be on the table. I think we will do one of those things if I’m elected governor.

Q: Are you going to make expansion and health reform issues in your campaign?

A: There are sort of two sides to this coin. What you’re talking about on some level is, what are the politics of it? And on another level, what’s the moral value, or what’s the correct policy option?

I’m not sure what the politics are, but I’m going to do what I think is right, no matter what.

I think that it makes economic sense for our state to ensure that we draw down our tax dollars and bring them back to Georgia to improve the health options that our citizens have, to improve the economics of our hospitals, to inject a giant amount of money into the economy.

The jobs impact of taking the billions of dollars back and not rejecting our own tax dollars is huge. Plus, it ripples out to having more productive, healthier citizens.

My impression thus far of the governor’s campaign is that they’re going to talk about “Obamacare” a lot. I think [with] the national dialogue on Obamacare, there are going to be books written about it. It has become whatever it has become as this political animal.

The bottom line is the Affordable Care Act [Obamacare] was passed by Congress, signed by the president and affirmed as constitutional by the Supreme Court. It is the law of the land, no matter what.

What has happened in my view is what we’ve seen in Georgia is that all the Washington politics about Obamacare have been imported. It doesn’t matter if I support 100 percent of the Affordable Care Act or not. There are things I would change, there are things the president would change. The question we have to confront as governor, is what’s best for the state, given the federal law.

This governor came from being in Congress for two decades and can’t let go of the Washington politics, and wants to use Georgia’s tax dollars and Georgia’s health and sacrifice it on this Washington politics altar of Obamacare, and say, we are not going to do this because of Washington politics, instead of looking at this, and say, what makes sense? We have to look as governor at what’s best for the citizens of Georgia.

To me, it is examining the best way to do an exchange, rather than just rejecting it. [Georgia, like a number of other states, lets the federal government run its exchange.] And examining the best way to take the health care dollars and reduce the size of our uninsured population.

Q: Can you comment on the argument that expansion will cost the state too much money?

A: What’s interesting to me about this rhetoric about the federal government is that it’s pick-and-choose. We don’t like Obamacare because Obamacare is unpopular. That’s pure politics. We like deepening the Savannah Harbor with federal dollars because, well, that is popular.

Georgia today under the current leadership is one of the most dependent states on the federal government in the country, and yet we sit here and blast the federal government all day, while we grow more and more dependent on it. Half of the time we’re begging for federal dollars.

I think we have to strengthen our state government in ways that make sense. We have to invest in the future. To the extent that we’re going to participate or not participate in federal programs, we need to look at what they are doing for our state. Are we investing in our future? Are we getting stronger? When we build roads, when we invest in our infrastructure, when we deepen the Savannah port, I think those things strengthen our state. I think it strengthens our state by injecting billions of dollars into our health care system to reduce the size of our uninsured population. Those things are investments in our future that don’t make us more dependent on the federal government.

We pay our federal tax dollars in Georgia, yet we’re going to try to pick and choose based on politics when we get the benefits of those tax dollars? That doesn’t make sense.

Q: There was another rural hospital that closed in Georgia last week – Lower Oconee Community Hospital in Wheeler County. That makes four to close in Georgia in two years. What are your thoughts on that issue?

A: It is a major crisis for a community when a hospital closes. Lower Oconee in Glenwood had 100 employees and 25 beds. The problem in a community like that when a hospital closes is not just that you’re losing health care options and not just that you’re losing jobs. The economic impact a hospital has in a community like that is gigantic. It also ripples out beyond that. If it takes 30 or 40 minutes to get to a hospital from that spot, it’s harder to put a factory or mill there. You’ve got someone operating a nail gun, you have someone operating a piece of machinery, and you’re nowhere close to a hospital. It makes it more difficult. Those things about rural Georgia and rural hospitals are incredibly important to me and to those communities.

We have to find a way to make those hospitals economically viable and sustainable. One piece of that, I believe, is to use our federal tax dollars that we’ve already paid that are waiting for us to reduce the size of the uninsured population. That uninsured population is just a giant hole in [hospitals’] budgets.

We have to find ways to have sustainable economic models for those hospitals going forward. It’s not just reducing the uninsured population. It’s also finding an appropriate mix of services that are going to work in those areas. I understand there are ways to approach that issue through the regulatory environment. It doesn’t have to be to open up [the certificate of need rules]. I think we can explore regulatory solutions. We haven’t seen that yet from this administration. This being an election year, as soon as we start talking about things, the administration has acted. Hopefully we’ll see some of that in a short period of time.

Q: The health plan that covers state employees and teachers has come under sharp criticism since changes were launched in January. What’s your view of this situation?

A: First of all, I’m on that same health plan. I not only heard complaints from citizens, but complaints from my wife. A very important constituent (laughs) . . . [Both Carter, as a state legislator, and his wife, a teacher, are eligible for the state health plan.]

I believe that we have to have options — more options than we have now. I think the outcry from teachers and others has been intense and powerful. And you saw, all of sudden it’s an election year, and we’re seeing a huge amount of responsiveness from the governor’s office. The flip-flop on whether we needed to use the reserves from the State Health Benefit Plan is not shocking, it’s just politics as usual.

We’ve spent $100 million out of the reserve fund as an attempt to placate the anger. It doesn’t actually solve the problem. We’re going to continue to hear from a great number of people, led in part by the teachers, that this is not enough. We’re talking about real options that need to be there.

The State Health Benefit Plan is a symptom of a much deeper-seated problem, which is the current leadership of our state doesn’t believe they need to take care of those teachers. They don’t have a respect for the work that gets done, and the desire to recruit and retain and support the best possible workforce that they can.

I think one other aspect of the current leadership’s ideology that is indicated by this decision is they don’t run the state with the belief that it can succeed as an entity. They’re so against “government” as a concept that they don’t believe in its success. If that’s true, you’re running a multi-thousand-employee entity with serious morale problems, with disrespect for the employees. . . . You end up with decisions like this that result in a backlash.

Q: Medical marijuana is an issue that seems to have come out of the blue, yet there’s momentum in the General Assembly to allow its use for children. Do you have a position on that?

A: I agree with you that it was an interesting and surprising development, given the makeup of the Legislature. I think the fact that it was a very conservative Republican from Middle Georgia who has led the charge is interesting.

But I personally tend to be a libertarian on things like this. . . . If you have a carefully crafted piece of legislation that’s going to minimize the unintended consequences, then I wouldn’t have a problem getting on board with it.

When you talk about the health outcomes for the kids that they’ve been discussing, you have to put those facts first, and whatever ideology there is, second, or not at all.

Q: Is health care going to be a big part of your campaign?

A: Part of a campaign is meeting people where they are.

Health care is an undeniably important part of our policymaking. The state government has a huge impact on the health care industry and the health care of its citizens. There are major problems that we’re confronting. There’s no doubt in my mind that it will be an important, crucial part of my governorship.

How the campaign plays out is too hard to know.

Q: Anything you want to add about health care?

A: I think it’s important that people get good information about the health care policy discussions because it’s so opaque.

If I buy a car muffler, I know exactly what it costs. If you go get an MRI, I haven’t found anyone who tells me how much it costs.

Q: The prices could vary by hundreds of dollars.

A: Not only that, but to different patients. Having a good, well-informed discussion about it is really important.

Q: Can the state do anything about making health care prices more transparent?

A: Yes, I think that the state can do that. Part of the problem is that [there is] so much volatility into the system with the staggered rollout of the different parts of the Affordable Care Act, we have to take a minute so see where that’s going to go. We don’t know what it’s going to do to costs.

But once we settle in, and understand what the [impact of] the federal law is going to be, I think there’s a variety of things the state can do, certainly from an informational standpoint. It’s not easy, but I do think transparency is one of the things that almost always helps.

 

 

Dental care for seniors — a need that goes largely unfilled

Photo courtesy of Mercy Care

Photo courtesy of Mercy Care

Johnnie Collier, 71, recently went to Mercy Care’s downtown Atlanta facility to have a tooth extracted. He said it had been hurting him for many years.

Another patient, David Perlete, 63, who is uninsured, also had a painful tooth pulled there. Other facilities charge hundreds of dollars, he said.

Despite the work of charity clinics like Mercy Care, millions of older adults are unable to get the dental services they need.

Traditional Medicare, the federal health insurance program for people 65 and older and the disabled, does not cover routine dental treatment. (Some private Medicare Advantage plans do offer some coverage.)

The VA, which provides a wide range of medical care to millions nationwide, provides dental care to only a few, very limited categories of veterans.

Medicaid for adults in Georgia covers only extractions, said James Peeples, a Mercy Care dentist. And he tells patients to get them done in time and not to wait until they need a root canal.

“Unfortunately, extractions have become a way of life for many of the older patients we see,” Peeples said.

A State of Decay, a report released last month by Oral Health America, describes a shortage of oral health coverage, a strained dental health workforce, and deficiencies in prevention programs across the nation. The report said the highest-ranking state for dental health is Minnesota, with a 92.9 percent score, while the lowest is Mississippi, with 29.3 percent.

Georgia, which has no dentist in 24 of its 159 counties, got an overall score of 62.4 percent, and was ranked “fair.”

Dental health is an important part of overall health. Experts agree, for instance, that a tooth abscess left untreated can lead to serious, even life-threatening, complications.

Among Georgians 65 years and older, almost one in four have lost all their teeth, according to the CDC’s State Oral Health Profile.

 

Short shrift for oral care?

“Georgia’s dentists have a grave concern about the elderly population in our state and the lack of safety net programs for oral health,” said Nelda Greene, the Georgia Dental Association’s interim executive director.

“We have some very good pro bono programs,” said Greene, “but it doesn’t take care of all needs and it is not a sustainable health care delivery system.”

“It comes down to funding,” she continued, and dental care gets low priority.

“It’s as if we cut off the oral cavity from the rest of the body,” she said. “If a senior citizen falls and breaks their arm, their health care needs are taken care of with medical benefits. Not so with oral health issues. And going to emergency rooms will not solve the problem of an abscessed tooth.”

People who can’t get regular dental care often wait until the problem becomes unbearable, then head to the emergency room. Because the ER is the only recourse many of them are familiar with, it has become the “go to” site for everything from serious tooth decay to a lost filling.

In 2007, 60,000 emergency visits for non-traumatic dental problems or other oral health matters occurred in Georgia, at a cost of $23 million, according to the Pew Center on the States.

The Georgia Dental Association’s Mission of Mercy has helped many patients in dire need of oral care at their clinics. One was held this year, and the next is planned for 2015.

Photo of Norcross clinic courtesy of Georgia Dental Association

Photo of  Mission of Mercy clinic,  courtesy of Georgia Dental Association

In addition, there are clinics such as Mercy Care. It provides some help for underserved patients in the Atlanta metropolitan area, based on a sliding scale to help cover costs.

Mercy Care Clinic’s manager, Denise Leon-York, said, “Older patients we get typically forgo dental work, because it’s not covered by Medicare.” When such people don’t get care promptly, the situation gets much worse, and they finally have to seek help.

The organization offers preventive, surgical, restorative and prosthetic services to people with low incomes, the homeless and HIV-positive clients.

“The older patients we see are at risk of a number of problems,” said Luis Limeres, a Mercy Care board member. The organization offers preventive, surgical, restorative, and prosthetic services.

“The problems from these patients can range from dry mouth caused by reduced saliva flow as a result of medications or cancer treatments to root decay caused by acids.”

Limeres continued, “Some patients have gum disease from plaque, poor diets, poorly fit dentures, and certain diseases like anemia and diabetes.” Some of the problems have been left untreated for extended periods of time.

“It is very hard for these patients to decide whether to replace a 20-year-old denture or take care of bills they have,” Limeres said.

Most retired Americans have no dental insurance.

 

A controversial proposal



CDC data show major disparities exist among dental care for residents of long-term care facilities, home-bound patients, and non-institutionalized adults.

To increase access to dental care in Georgia, an upcoming legislative proposal would allow dental hygienists in safety net clinics to provide care under the supervision of a dentist without the dentist being physically present.

Currently there are two notable exceptions where a dental hygienist does not need a Georgia dentist to be present — a Department of Public Health program and in a Department of Corrections facility, the Georgia Council on Aging says.

According to the council, Georgia is one of only five states in the country that require direct supervision of a dental hygienist by a dentist. The effort to give more latitude to dental hygienists has been a touchy political issue in Georgia.

The dental association’s Greene, asked about the proposed legislation, said, “The Georgia Dental Association believes a team approach is best for patients.”

“Dentists have the most education and training and are the oral health professional [and they] can examine and diagnose signs of oral cancer, gum disease or other health issues,” she said.

Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.

 

Answers about expansion and exchanges, from the head of CMS

Marilyn Tavenner recently was confirmed by the U.S. Senate as the administrator of the U.S. Centers for Medicare & Medicaid Services (CMS).

It’s a big job, made even bigger by the Affordable Care Act, which is set to be fully implemented in January.

The 91-to-7 Senate vote showed bipartisan support for Tavenner, who had been principal deputy administrator at the agency.

A former HCA executive who began her career as a nurse, Tavenner came to Atlanta on Wednesday and spoke to a conference sponsored by the Georgia Chamber.

She also met with GHN for an exclusive interview, in which she discussed the law’s requirements, the individual states’ decisions on Medicaid expansion, and the challenges ahead as CMS gears up for health insurance exchanges to begin enrollment Oct. 1.

Q: Many states, including Georgia, have decided not to expand Medicaid. How does that impact the overall effectiveness of the Affordable Care Act?

A: When the Supreme Court ruled that the expansion was optional, or up to states, we started to re-project our numbers. It certainly decreases the number of people who will have coverage. But inside each state . . . we’ve tried to meet each state where they are.

If folks want to do a partial expansion, we’re still willing to do that under the old rules. It wouldn’t be at a 100 percent federal match; it would be at the traditional state match.

We’ve tried to send the signal that if you’re willing to do this in stages, we want to be there, we want to help. But there’s no doubt, in the states deciding not to expand, those below 100 percent [of the federal poverty level] will be missing [from coverage expansions].

I think the important thing for us is we have the federal marketplace available in those states, so at least we can pick up folks 100 percent and up, such as [in] Georgia, Louisiana and others, that have elected not to expand.

Fortunately, we have a strong regional office here in Atlanta. Atlanta probably has more of the pressure, because they have responsibility over several states that are not expanding.

With the [health insurance] navigator work, we’ll be working with not-for-profits and other partners to get the word out. We will insure everyone we can.

One of the unintended benefits is that when we start talking to folks, even some of the people currently eligible for Medicaid as it exists today in Georgia will get picked up [for coverage].

Q: Some states are talking about doing an expansion of Medicaid through the private market, with private insurers. What’s the administration’s position on that? 

A: Several states have talked about it. There’s actually one state that’s moving forward – that’s Arkansas. Although it’s still a Medicaid expansion, they’re using premium assistance. It’s been around and available, but it’s never been used on a wide-scale basis. So this will be our first waiver, our first demonstration. It will be on a statewide basis. We are actively working with Arkansas. To be honest, we have not seen any showstoppers. We think it will be the first demo to do premium assistance. This will entitle folks to all the Medicaid benefits and protections. It allows them to do the expansion.

Q: What is premium assistance?

A: Instead of having the Medicaid fee-for-service model, all these individuals will go into some type of private insurance plan.

Q: Many people have expressed doubts that the health insurance exchange will meet its deadlines and will be ready to go as scheduled. 

A: The GAO [Government Accountability Office] had a report out today as well [on exchanges possibly missing the open enrollment deadline Oct. 1].

It’s speculation. We will be ready. Now, will we make modifications as we go along? Certainly. But so far, we have met our deadlines. We have perhaps three regulations to get out. They’ll be coming out – some soon, some over the summer. We’re pretty much on schedule with that. We’re actively testing [systems]. . . .

I’ve just finished a series of calls, talking with each Medicaid director and each exchange director. I’ve got four or five more to go. I’m very encouraged that everybody is meeting deadlines.

Q: Will the exchanges provide a competitive market for insurance?

A: Here’s my honest opinion about that. Today, Atlanta is a classic example – Atlanta will remain competitive. We will have good premiums, and we will have the additional protections of the Affordable Care Act – no pre-existing conditions [that can bar coverage], no lifetime limits. It will have a better product at a competitive price.

There are some marketplaces that are not competitive. In my opinion, this project may take two, three, four years to change a non-competitive market into a competitive market.

But it will allow consumers to start getting educated about what’s available in their market. People start understanding what they’re paying for, what they’re receiving.

I think there will be some large insurers that will come in slower. But I think we’ll see more and more competition.

It’s really very much a private-based model. We’re using private insurers. It will grow over time. But I don’t think noncompetitive markets will become instantly competitive. It will take some time.

Q: There’s a tremendous effort ahead in educating people about the law’s requirements. What are the biggest challenges in this area?

A: Because of all the political theater over the last couple of years, the Supreme Court decision, the election last fall, there was a lot of back and forth. It’s really only been, in my opinion, in the last two months that we’ve had a really clear field about starting to get the message out about the Affordable Care Act and what it does.

Quite honestly, I try not to say the ‘Affordable Care Act,’ because it creates this feeling about whether it’s good or bad. But if I go one step below, about what we’re trying to do, people get interested. Most people want health insurance, they want some protection. They understand the importance of prevention.

I think we spend between now and September talking about what’s beneath the Affordable Care Act – what we’re trying to do – to increase access, improve quality and deal with costs.

In September, we change to ‘You’re John Smith, we want you to sign up for insurance.’ Then it becomes very targeted.

Q: Then it becomes about enrolling people. How will you accomplish that?

A: There are several ways to approach it. The navigators are one. We just put out a $50 million funding opportunity across the federal exchanges. The state exchanges have their own funding pool. There are people who will train. There are associations that naturally will gravitate to this and want to do this. We’re in the process of reviewing those applications now.

The second avenue is the website [www.healthcare.gov]. If you and I want to go to the website and sign up, and check to see what we qualify for, we will be able to do it without a navigator, so you can do it independently.

We’ll have a 1-800 call center similar to Medicare numbers today. We have different levels of training and skill sets. If you have a basic question, or if you want to really start to dig into your account, we have different levels of training.

Q: How will you get basic information out to consumers – what they need to pay attention to?

A: We actually started some of that last week. States have started their television and media campaigns . . . State-based exchanges have a great deal of independence.

We’ll be doing that – TV, radio, print. We’ll being doing it through the call center, and through the website.

Q: There are employers trying to get out of some of the law’s mandates. Such as hiring people to work under 30 hours a week, who won’t be considered full-time employees; keeping a workforce under 50 full-time employees, so the company doesn’t have to offer insurance; providing bare-bones plans and driving people into the exchanges. What’s your response to these moves? 

A: For large employers, they had a lot of grandfathering protections. So for them, I won’t say it’s business as usual, and there were certain things they had to add, such as insuring [dependent children] up to age 26.

There are some things that are different for them, but as I remind them, they should also see the cost benefit. We’ve seen the lowest cost increases [during] the last three years. First, folks said it’s the economy [holding the costs down], but now most economists are saying that we can’t say it’s the economy. I’ve tried to make the point that for large employers, I’m not seeing this desire to get out of the business [of providing insurance].

I’m sure they’re looking at the 30-hour issue. That’s a real issue – I’m not making light of that.

If you have less than 50 employees, you don’t have to offer health insurance. We hope you do, but there’s no penalty; you are exempt. That’s the majority of startup businesses.

What we are trying to do is make marketplaces competitive so you want to offer insurance as a recruitment tool, as the right thing to do for the employee, and the employee’s family.

There’s a lot of misconception about who has to pay the penalty. The folks who will have to pay are the people who are above 50 [employees] and choose not to offer insurance, and who have someone who actually goes to the exchange.

That’s a small population of employers. Most employers are either below 50, or fall into those who traditionally offer insurance.

So I think a lot is being made about a very small segment of the market.

Q: You were here recently speaking to large employers. What was discussed?

A: We had a closed meeting at Grady Hospital, and I met with large employers. We had this very good debate back and forth. I was talking with one of them in the hallway [today], and he said, ‘I’m surprised you came back. We gave you a hard time.’ And I said, ‘I was surprised to be invited back.’

I’m OK with getting a hard time. I actually think it was a good dialogue. I wanted to hear from them about kind of the cost trends they were seeing, and they were good. But they did have concerns about the Cadillac tax [on expensive benefits plans] and covering [people's children] up to age 26. It was an open dialogue at what we need to look at long term, where we can make improvements. It was a give and take.

Q: What do you want to emphasize about all these changes?

A:  I would like to emphasize the points I made about access, cost and quality. Access is one big piece of it, and obviously it’s the part we’re rolling out in the fall. But we’re really trying to look at all three areas.

Folks have been complaining bitterly about health care for years. Everyone complains, but no one really offers a long-term solution. This is an attempt at a long-term solution to a problem this country has recognized for years. Is it perfect? No. Will it have to be modified over time? Absolutely.

But it’s a step forward. We can’t do it without industry support, without advocacy support. I’d like to emphasize we’re all in this together. I want to work together with folks.

 

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