The Affordable Care Act is on the move in Western states, with the governors of Utah, Wyoming and Montana all working to hammer out deals with the Obama administration to expand Medicaid in ways tailored to each state.

But getting the federal stamp of approval is just the first hurdle — the governors also have to sell it to their legislatures who have their own ideas of how expansion should go.

The latest case-in-point is Montana, where the governor and the legislature have competing proposals about how much federal Medicaid expansion cash the state should try to pull down.

Montana’s GOP-dominated legislature, which meets every other year, rejected Democratic Governor Steve Bullock’s attempts in 2013 to expand Medicaid and set up a state-based insurance exchange. This year Bullock has a different Medicaid expansion proposal aiming to reduce the Treasure State’s 17 percent uninsured rate. It would use federal dollars to contract with a third party administrator to process claims and run a provider network. So far Republican leaders are not embracing it any more than they did his 2013 plan.

Nine Republican state lawmakers last week released an alternative proposal, the “Healthy Montana Family Plan.”  It rejects the approach by Bullock and the White House that Medicaid should be offered to anyone making less than 138 percent of the federal poverty level (FPL), or $16,105 a year. That would be about 70,000 people in this sparsely populated state with just over 1 million residents.

Instead, the plan would extend Medicaid only to certain categories of people who make less than 100 percent of the federal poverty line, or $11,670. The idea is to “keep it targeted toward what it’s intended to do,” said plan co-author Sen. Fred Thomas, “take care of our most vulnerable citizens … disabled persons, low income seniors, low income parents, children.”

“Able-bodied people should be able to go out and get a job,” incoming Republican House Speaker Austin Knudsen told the Billings Gazette.

Thomas, an insurance agent by trade, says that extending Medicaid to non-disabled adults who don’t have children is “a disincentive to work.”

How should an uninsured adult without kids who makes less than $11,670 get coverage? Thomas says the focus should be on boosting that person’s  income: “Anyone that’s in that predicament, we’re gonna encourage them to get another job, get the extra hours, and qualify for the exchange, by bumping their income up a little bit.”

He points out that, under the Affordable Care Act, low income people who make at least 100 percent of FPL qualify for premium subsides through healthcare.gov, which makes health coverage “pretty economical,” or nearly free.

The plan he co-authored says: “Policymakers could employ income tax credits in certain circumstances to boost incomes of those without Medicaid access above 100 percent FPL in order to take advantage of sliding-scale exchange subsidies.”

That reliance on subsidies could hit a snag if the Supreme Court decides in June that it is illegal for those tax subsidies to flow to states that are using healthcare.gov rather than setting up their own exchanges.

The Montana Republican health plan also echoes policies advocated by former Obama administration Medicaid and Medicare leader Don Berwick. It calls for new contracts with providers that require them to take on some risk and responsibility for the health of the population. The contracts would reward hospitals and doctors based on “metrics that focus on health outcomes, patient satisfaction and cost containment,” what Berwick calls the “triple aim.” The health law enacted many of those rewards and penalties for hospitals that treat Medicare patients.

This story is part of a reporting partnership that includes Montana Public Radio, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

In December, the Food and Drug Administration approved a new anti-obesity drug, Saxenda, the fourth prescription drug the agency has given the green light to fight obesity since 2012. But even though two-thirds of adults are overweight or obese — and many may need help sticking to New Year’s weight-loss resolutions — there’s a good chance their insurer won’t cover Saxenda or other anti-obesity drugs.

The health benefits of using anti-obesity drugs to lose weight—improvements in blood sugar and risk factors for heart disease, among other things—may not be immediately apparent. “For things that are preventive in the long term, it makes plan sponsors think about their strategy,” says Dr. Steve Miller, the chief medical officer at Express Scripts, which manages the prescription drug benefits for thousands of companies. Companies with high turnover, for example, are less likely to cover the drugs, he says.

“Most health plans will cover things that have an immediate impact in that plan year,” Miller says.

Miller estimates that about a third of companies don’t cover anti-obesity drugs at all, a third cover all FDA-approved weight-loss drugs, and a third cover approved drugs, but with restrictions to limit their use. The Medicare prescription drug program specifically excludes coverage of anti-obesity drugs.

Part of the reluctance by Medicare and private insurers to cover weight-loss drugs stems from serious safety problems with diet drugs in the past, including the withdrawal in 1997 of fenfluramine, part of the fen-phen diet drug combination that was found to damage heart valves.

Back then, weight-loss drugs were often dismissed as cosmetic treatments. But as the link between obesity and increased risk for type 2 diabetes, heart disease, cancer and other serious medical problems has become clearer, prescription drugs are seen as having a role to play in addressing the obesity epidemic. Obesity accounts for 21 percent of annual medical costs in the United States, or $190 billion, according to a 2012 study published in the Journal of Health Economics.

The new approved drugs — Belviq, Qsymia, Contrave and Saxenda — work by suppressing appetite, among other things. Saxenda is a subcutaneous injection, the other three drugs are in pill form. They’re generally safer and have fewer side effects than older drugs. In conjunction with diet and exercise, people typically lose between 5 and 10 percent of their body weight, research shows, modest weight loss but sufficient to meaningfully improve health.

The drugs are generally recommended for people with a body mass index of 30 or higher, the threshold for obesity. They may also be appropriate for overweight people with BMIs in the high 20s if they have heart disease, diabetes or other conditions.

In 2013, the American Medical Association officially recognized obesity as a disease.

Nevertheless, “people still assume that obesity is simply a matter of bad choices,” says Ted Kyle, advocacy adviser for the Obesity Society, a research and education organization. “At least half of the risk of obesity is inherited,” he says.

Many people who take an anti-obesity drug will remain on it for the rest of their lives. That gives insurers pause, says Miller.

The potential cost to insurers could be enormous, he says.

Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group, says the variability of insurer coverage of anti-obesity drugs “relates to issues of evidence of effectiveness and evidence of safety.”

In 2012, the U.S Preventive Services Task Force, a non-partisan group of medical experts who make recommendations about preventive care, declined to recommend prescription drugs for weight loss, noting a lack of long-term safety data, among other things. But its analysis was based on the older drugs orlistat, which is sold over the counter as Alli or in prescription form as Xenical, and metformin, a diabetes drug that has not been approved for weight loss but is sometimes prescribed for that by doctors.

The task force did recommend obesity screening for all adults and children over age 6, however, and recommended patients be referred to intensive diet and behavioral modification interventions.

Under the health law, nearly all health plans must cover preventive care recommended by the task force without cost sharing by patients. Implementation of the obesity screening and counseling recommendations remains a work in progress, say experts.

Dr. Caroline Apovian, director of the Nutrition and Weight Management Research Center at Boston University, says many of the patients she treats can’t afford to pay up to $200 a month out of pocket for anti-obesity drugs.

“Coverage has to happen in order for the obesity problem to be taken care of,” says Apovian. “Insurance companies need to realize it’s not a matter of willpower, it’s a disease.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Born just a year apart, Oliver Massengale and his brother Charles grew up together. Now, in a two-story home in Compton, they are growing old together. But Charles Massengale, 71, can do little on his own.

The former tree trimmer has severe brain damage from a 30-foot fall, as well as dementia, diabetes and high blood pressure. Six years ago, Oliver took over as his brother’s full-time caregiver, paid about $10 an hour by the state.

It was not a job he was trained to do.

“I didn’t have a clue,” said Oliver, a retired grounds manager at a college. “I was just so afraid of what I was doing.”

He constantly worried – about giving Charles the wrong medication, about him getting bedsores, about his blood pressure. And he had no idea how easily his brother could fall over. One day, he was cooking and Charles was on a stool at the kitchen counter.

“I heard BAM,” he said. “I turned around and he was on the kitchen floor.”

No overall training is required for the more than 400,000 caregivers in California’s $7.3 billion In-Home Supportive Services Program (IHSS) for low-income elderly and disabled residents. Without instruction even in CPR or first aid, these caregivers can quickly become overwhelmed and their sick or disabled clients can get hurt, according to interviews with caregivers, advocates and elder abuse experts.

The lack of training is “of enormous concern,” said Gary Passmore, a vice president of the Congress of California Seniors, an advocacy organization. “We are dealing with a lot of frail, elderly people.”

The need for in-home caregivers is rising as the elderly and disabled population grows. The demand for personal aides – most of whom work in the home — is expected to increase by 37% over the next decade, requiring about 1.3 million new positions, according to research published last year by the New-York based Paraprofessional Healthcare Institute, an advocacy group that also provides training.

The federal government is trying to meet that need by stepping up efforts to expand and train the work force. But for now, there are no federal training requirements for in-home-caregivers. It’s up to states to set them in Medicaid-funded programs like California’s. As a result, training policies vary dramatically.

In California’s IHSS program, clients are in charge of hiring, managing and training their own caregivers. The program stands out because of its sheer size — it is the nation’s largest publicly funded home care program – and because such a high percentage of caregivers are relatives directly employed by the clients rather than agencies, said Abby Marquand, director of policy research for the Paraprofessional Healthcare Institute.

“It is a lot easier to ensure a minimum level of training if the person is employed through an agency,” she said.

IHSS was never intended to be a medical program. The caregivers are distinct from visiting nurses and the certified home health aides often dispatched after a hospital stay. IHSS caregivers are not certified or licensed and are hired to do personal care and household tasks.

But more than a quarter of IHSS clients are 80 or over, and many have chronic health conditions or dementia. In these and other cases, caregivers can end up providing basic medical care–helping to administer insulin shots, manage other medication or dress wounds, for instance.

When such “paramedical” services are needed by individual clients, IHSS caregivers are required to get instruction and approval from a health care professional. But the state doesn’t sponsor the training or pay caregivers more for getting it. Only 12 percent of clients have caregivers who have received it.

Eileen Carroll, deputy director of the California Department of Social Services, which oversees IHSS, said the program doesn’t have a lot of training requirements because it was set up to give clients the choice of how they want their care delivered.

For caregivers who want it, the state offers comprehensive voluntary training information online on topics such as fall prevention and use of medical equipment, she said.

Carroll said many people are fully able to direct their own care and supervise their caregivers, but some aren’t. “Our task is how to work harder to support those who have greater need,” she said.

Oliver Massengale, for example, can’t depend on his brother to tell him what he wants or needs — Charles no longer talks much. “Because of the nature of the injuries and his different ailments, he could never train,” Oliver said. “He can’t even take care of himself.”

The situation worsened recently because Charles’ health insurance plan changed, and he no longer is being visited by a nurse. So every day Oliver sits inches from Charles, checking his blood pressure and blood sugar and coaching him step-by-step on how to inject insulin into his own arm.

“Hold the back of that needle up,” he told Charles on a recent day. “Put it in right there. Now pump the medicine in. Good, good.”

When he heard about a training class in Los Angeles, Oliver said he jumped at the chance.

“If I’d had this class in advance, it would have made it a lot easier,” he said.

A sensitive matter

Whether or not to require training for those who care for California’s 490,000 low-income elderly and disabled home care clients is a sensitive political — and personal — issue.

Carroll said the state is in a tough situation. Training is a positive thing, she said, “but you have a very strong adult disabled community in this program who … oppose any mandatory training.”

Many disability rights advocates say a training mandate would make it more difficult for IHSS consumers to find caregivers, chip away at clients’ autonomy and drain resources from the program.

“The idea of choice is really paramount,” said Deborah Doctor, legislative advocate at Disability Rights California. “Anything that puts a requirement that erodes that choice is a problem.”

Relatives, who make up nearly three-quarters of paid IHSS caregivers, often say they know what is best for their loved ones. And clients are inclined to trust family members and say they can instruct them on what they need.

“A mother who has been taking care of a child for 20 or 30 or 40 years doesn’t need mandatory training on how to take care of that person,” Doctor said.

Training should be made available to those who want it, but should be entirely voluntary, said Nancy Becker Kennedy, who was paralyzed in a diving accident 40 years ago.

“There is no one size fits all,” said Becker Kennedy, who founded IHSS Consumers Union, a group that advocates for both consumers and workers.  “The population is much too diverse to mandate anything across the board.”

Many other clients agree. Sheela Gunn-Cushman, who is blind, diabetic and has mild cerebral palsy, lives with roommates in San Lorenzo, Calif., with the help of an IHSS caregiver whom she trained herself.

“I don’t feel like anyone is capable of training a [caregiver] about what I need better than I do,” she said. “I am capable of telling them what I need.”

A union that represents caregivers, however, sees advantages to a minimum level of training.

SEIU-United Healthcare Workers West proposed a statewide initiative last year that would have required 75 hours of training, but the union didn’t get enough signatures to put the measure on the ballot. SEIU plans to try again for the 2016 ballot.

Requiring training would “save lives,” said Loretta Jackson, who serves on the union’s executive board and is an IHSS caregiver in Sacramento. It would also reduce the risk of injuries to caregivers, she added.

Jackson cares for her sister, who was left partially paralyzed by a stroke 15 years ago. When Jackson first started, she had to call paramedics every few weeks because her sister would fall. Once, Jackson said, her sister took too many pills and started shaking violently.

“I didn’t know what to do,” she said. “I started panicking.”

Other caregivers tell similar stories.

Ariana Ramos, 28, who is taking a training class, said a paralyzed client got a bed sore after sleeping in his wheelchair. Ramos thought it would heal on its own, but it just got worse.

“Now I know that we need to keep it covered up,” said Ramos, who lives in South Gate. “Now I know about bacteria and all the things that could get in a bed sore.”

Caregivers without any medical background or training may not know when to call 911 or how to recognize a heart attack or stroke, said Frances Chuc, who takes care of her paralyzed husband at their home in South Gate and was trained as a nurse aide before she met him. “That person could die in their hands.”

A little bit of training can go a long way, said Joanne Spetz, director of UC San Francisco’s newly created Health Workforce Research Center. It can help caregivers recognize when their clients are having bad reactions to medications, for instance, or help them safely lift a person to avoid falls.

Training can also reduce turnover in a field that has low job retention, said Marquand of the Paraprofessional Healthcare Institute.

Several states are experimenting with different models of training. Washington State, for example, began requiring 75 hours of training for home caregivers in 2012.

It doesn’t make sense that caregivers in the home require less training nationwide than caregivers in nursing homes, said Charissa Raynor, executive director of the SEIU Healthcare NW Training Partnership, which trains 40,000 providers annually. (Certified aides in nursing homes are required by the federal government to have 75 hours of training.)

The Washington initiative, Raynor said, will help professionalize the workforce, reduce on-the-job injuries and lead to better care.

But not everyone has been happy with the new mandate.

“There are a lot of folks who just want to be a caregiver in someone’s home,” said Betty Schwieterman, director of systems advocacy at Disability Rights Washington. “They are not on a career path.”

Grants From The Government

The debate over mandatory training is far from resolved. But in the meantime, the federal government is putting money into pilot training efforts in various states.

Through the Affordable Care Act, it has awarded about $15 million in grants to California and five other states to recruit and train qualified caregivers for the elderly and disabled populations. Classes started in 2011 in cities throughout the state, including San Francisco, Anaheim and Walnut.

The class Massengale attended is part of a separate federal grant of nearly $12 million given to the California Long-Term Care Education Center in Los Angeles. The center is training about 6,000 IHSS caregivers in Los Angeles, San Bernardino and Contra Costa counties.

An early evaluation of the program by UC San Francisco researchers shows that clients with trained providers are less likely to go to the emergency room or be admitted to a hospital than those with untrained providers.

Corinne Eldridge, who runs the program, said trained caregivers can play an important role on a client’s health care team. “They can be the eyes and the ears in the home … and communicate back to the health care provider,” she said.

At a recent session in Compton, about two dozen caregivers gathered in a classroom at the public library, their binders of training materials spread out before them. The topic of the day was preventing bed sores and controlling infections.

The teacher, nurse Lori Picou, asked the class about the signs and symptoms of infection. The students yelled out answers: Redness. Fever. Fluid or discharge.

One offered a story about a bruise that swelled up like a basketball. Another said her paralyzed son was sweating so much that she had to repeatedly change his shirt.

Picou reminded the group to wash their hands frequently. “It is one of the most important things an individual can ever do to help control infection,” she said.

Oliver Massengale, who is in the class, said he is feeling a little bit more confident about keeping his brother safe. “The more I learn, the better I am to cope with this,” he said.

But being a caregiver for someone with so many health conditions is still scary to him.

“As I come down those stairs,” he said, “I am saying a prayer and just hoping that everything is all right when I get to the bottom.”

Blue Shield of California Foundation helps support KHN coverage of California.

The California Endowment helps support KHN coverage of California.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.