Add Tennessee and Kansas to the list of states that have received warnings from the Obama administration that their failure to expand Medicaid under the Affordable Care Act could jeopardize special Medicaid funding they get to cover treatment of the poor.

The Centers for Medicare & Medicaid Services confirmed Tuesday that it gave officials in those states the same message that was given to Texas and Florida about the risk to funding for so-called “uncompensated care pools,”  or money that goes to hospitals and doctors to cover the cost of care for the uninsured.

The letter to Florida officials last week drew the ire of Republican Gov. Rick Scott who said the federal government should not link the $1.3 billion in uncompensated care funding with the state’s decision not to expand Medicaid. He has threatened a lawsuit against the Obama administration if it cuts off the funding, which is set to expire June 30.

The Texas funding is scheduled to end in September 2016. Officials there have also expressed indignation at what they perceive to be coercive pressure and talked about joining Scott’s lawsuit.

Kansas Medicaid officials said they received about $45 million this year in federal funding for their state uncompensated care program, which began  in 2013 and is slated to continue through 2017.

Tennessee Medicaid spokewoman Kelly Gunderson said her state gets over $750 million in federal funding to cover uncompensated care.

The message was delivered in Tallahassee last week in a letter from Vikki Wachino, acting director of the Center For Medicaid and CHIP Services, to Florida state officials. She wrote that expanding Medicaid coverage is a better way to help patients and providers than an “overreliance on supplemental payments” to providers. In addition, she said, expanding Medicaid would reduce providers’ uncompensated care costs and boost their revenue.

“Coverage rather than uncompensated care pools is the best way to secure affordable access to health care for low-income individuals,” she said in the April 14 letter to Florida Deputy Director For Medicaid Justin Senior.

CMS spokesman Aaron Albright said Tuesday the Obama administration wants to apply the same principles to all the states that receive such funding, whether or not they expanded Medicaid.

“We’ve been in contact with those states that have uncompensated care pools and reiterated that we look forward to an ongoing dialogue to develop a solution that works for patients, hospitals and the taxpayer,” he said. “We told states that our letter to Florida articulates key principles CMS will use in considering proposals regarding uncompensated care pool programs in their states, but that discussions with each state will also take into account state-specific circumstances.”

CMS officials confirmed they have also reached out to states that expanded Medicaid about the future criteria for the funding, including California, Massachusetts, Arizona, Hawaii and New Mexico.

Each state has negotiated its own program with the federal government to pay providers for treating the uninsured. But the programs differ in scope, funding and length of time remaining.

Judy Solomon of the left-leaning Center on Budget and Policy Priorities said the special federal funding that some states negotiated for uncompensated care was never supposed to last indefinitely. The need for the funding changed dramatically as millions of people gained health coverage under the health law, she said.

“These demonstration programs are at the discretion of the Secretary of HHS and there is no entitlement to any state or providers to continue these funding arrangements when they expire,” Solomon said, adding, “The need for uncompensated care funding is changing dramatically.”

Arizona Medicaid spokeswoman Monica Higuera Coury said her state, which did expand Medicaid, was also told that the special funding would begin to be phased out this year. Arizona receives a maximum $137 million a year to offset uncompensated care costs at Phoenix Children’s Hospital.  “We are looking forward to working with …CMS to put a transition plan together that moves us away from total reliance on the [funding] while still protecting this very important safety net for our children,” she said.

Some experts were surprised the Obama administration linked Medicaid expansion to the special funding because of the potential legal issues.

“No one would be shocked to hear that states don’t need the money because uncompensated care has dropped … but saying you are taking away this money because you are not expanding is trickier,” said Charlene Frizzera, a senior advisor at consulting firm Leavitt Partners.  “People are shocked that CMS has done that.”

But Joan Alker, executive director of Georgetown University’s Center For Children and Families, said the administration was simply acting as a steward of taxpayer money.

“I wouldn’t call it hardball, but rather responsible policy and fiscal oversight to ensure that federal tax dollars are spent in the most effective way,” she said. “When coverage is available to reduce the number of uninsured people  … and states refuse those funds, why should the federal government provide them with unauthorized funding to put a Band-Aid on it?”

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

That’s what Alexandra Robbins wrote in an opinion piece in the Washington Post last week (“Nurses make fun of their dying patients. That’s okay.“): “Humor has a place in hospitals, even if it’s dark, even if it’s derogatory — as long as it isn’t cruel.” Do you agree? And if you agree, how do you Continue Reading

Despite the government’s push to make health information more available, few people use concrete information about doctors or hospitals to obtain better care at lower prices, according to a poll released Tuesday.

Prices for the health care industry have historically been concealed and convoluted, unlike those for most other businesses. The 2010 health law aimed to make such information more transparent. People shopping for insurance can now compare the prices of competing plans through online marketplaces, including premiums, deductibles and their share of any medical expenses. The federal government also publishes more than 100 quality ratings about hospitals, as do some large private insurers. Private groups such as Consumer Reports and U.S. News & World Report also rate providers, and Internet forums such as Yelp are now littered with easily accessible opinions.

The poll from the Kaiser Family Foundation found that about two of three people say it is still difficult to know how much specific doctors or hospitals charge for medical treatments or procedures. (KHN is an independent program of the foundation.) Only about one in five people said they had seen specific cost or quality information about a hospital, insurer or doctor.

The poll found that this information rarely makes a difference. About 6 percent of people ever used quality information in making a decision regarding an insurer, hospital or doctor. And fewer than 9 percent used information about prices, most commonly in relation to health plans. Only 3 percent said they used price information about physicians, the poll found.

This lack of practical information may be related to another major finding from the poll: people are overconfident about their ability to pay medical bills without financial strain.

A majority of people told pollsters they had enough insurance coverage or money to pay for their usual medical costs or for an unplanned hospitalization. A majority also said paying insurance premiums, deductibles and their share of medical costs was relatively easy.

However, when asked how they would handle an unanticipated $500 medical bill, only 47 percent of insured adults under 65 said they would pay the bill in full immediately. The others said they would put it on a credit card and pay it out over time, borrow money or not be able to pay the bill at all. Not surprisingly, those bills would be a bigger problem for those who lacked insurance.

If the medical bill were $1,500—a sum that is less than the deductible in many insurance plans— 25 percent of people with insurance thought they could pay it off immediately. Another 29 percent said they would add it to their credit card debt, and 25 percent said they could not pay it at all.

The poll was conducted April 8 through 14 among 1,506 adults. It has a +/- 3 percentage point margin of error.

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

The Affordable Care Act mandates that all Americans get health coverage or pay a penalty. To help people pay for that insurance, the federal government subsidizes insurance premiums for millions of Americans.

In just a couple of months, the Supreme Court will rule in a major case concerning those subsidies. The question is whether the law allowed for them across the country or just in the minority of states that set up their own insurance exchanges. A decision to take away those subsidies could leave millions without insurance.

Attorney Tom Goldstein, who runs SCOTUSblog, has been following the case and says the law is ambiguous. “This is a real, serious question,” he says. “The law doesn’t tell you whether Congress wanted to limit the subsidies only to those states where the state itself went to the trouble of setting up the exchange or whether Congress wanted everybody who needed the help to be able to get the subsidies.”

Louisiana is a state where a lot of people could be affected. It runs healthcare.gov and about 186,000 people there have used the site to buy health insurance. Nearly 90 percent of them in Louisiana get subsidies.

We traveled to the state to interview many of these people who could lose subsidies if the Supreme Court rules against them. Here are our first three profiles:

Carlton Scott

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Carlton Scott is 63. Sitting at his kitchen table at the house he owns in Prairieville, near Baton Rouge, he says he worked at a chemical plant for 30 years before he retired. He found out last fall that his company was scaling back his retiree benefits.

“’Round October they wrote me a letter saying, in December we’ll no longer be covered,” he says.

That included his health insurance, which he was really counting on.

“I thought they would take me to my grave. I really thought the company would take me to my grave,” he says. When it went away, “That pissed me off. Because, god——, I been through 30 years and you come with this bullsh–? That pissed me off.”

And he was in a bind. At 63 he is too young for Medicare and Louisiana hasn’t expanded Medicaid. Obamacare was a good option for him.

He signed up for a BlueCross BlueShield of Louisiana plan. He says he pays $266.99 per month, “to the penny.” Like a lot of people, he could rattle off the exact amount. Money is tight and people track their expenses carefully.

Scott could be in a position to lose his subsidy and his health insurance. He says if he had to pay more, he could for a while. He gets $2,600 a month between Social Security and his pension. But he worries about his friends.

“Everybody don’t make the same amount of money, that’s what I’m saying. I got a friend of mine, stay down the street. He gets Social Security and pension, too. But it’s not as much as mine, not half as [much].”

When asked about the case in front of the Supreme Court, he laughs.

“They all got insurance, too. I guarantee you that. They all got insurance.”

He says the court should, “Leave it like it is. I mean, what are people going to do? Get sick, go to the hospital, ‘I don’t have insurance. Won’t you please help me anyway?’ Hell, no. That ain’t going to happen,” he says.

LaTasha Perry

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LaTasha Perry is at the other end of her career. She’s 31 and works at the front desk of a community health center in Plaquemine, La. She got covered under Obamacare because it was cheaper than paying the penalty.

She says her children have Medicaid as their health coverage. Her job offers health insurance, but she says she can’t afford to buy it.

“I would pay at least $100 a month for the insurance here,” she says. “With my subsidy, I pay $13.”

Now she’s got money left over for necessities: “Food for my kids. I’m a single parent, so it’s hard.”
 

Charles Dalton

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Charles Dalton wanted health coverage. He’s 64 and after he retired as a paramedic, he didn’t have health insurance. Then he got sick. He says his condition is too personal to talk about. “I’m disabled,” he says. “But I would be totally incapacitated without seeing this doctor.”

The Affordable Care Act says insurers can’t take into account whether somebody is sick, like they used to. That made insurance unavailable or unaffordable for many sick people. And now — with subsidies — Dalton says he pays $149 a month. He hopes the Supreme Court doesn’t touch the subsidies.

“They’re just going to make a difficult situation more difficult,” he explains. “Because of the Affordable Care Act, it’s helping me to be able to make this existence more livable. You’re not asking for a handout. But if you get a helping hand, the last thing you need is for it to be snatched out from under you.”

Regardless of the politics, there are a lot of people like Dalton who could feel that the Supreme Court would be taking something away. Goldstein of SCOTUSblog says the court has a tough job.

“This is a case that requires the justices to be both lawyers and try and look at the words that Congress used, but also to struggle with the human dimension of the case,” he says. “The consequences are so real and so powerful that, if the challengers win here — and maybe they deserve to win, maybe it’s what Congress intended — but it’s hard to avoid the conclusion that millions of people would lose access to health insurance.”

This story is part of a reporting partnership that includes WNPR, 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.

It’s been more than 20 years since passage of the landmark Family and Medical Leave Act, which allows workers to take up to 12 weeks of unpaid time for medical or family reasons without losing their jobs. Some advocates and politicians say it’s time to plug a big hole in the law by requiring that workers get paid while they’re on leave. But the measure faces stiff opposition from some small business and other groups.

Saying the reality for many families is that both parents must work, President Barack Obama has pushed for paid family leave, calling it an “economic necessity” in his January State of the Union address. He proposed $2.2 billion in next year’s budget to help five states get paid leave programs up and running, and an additional $35 million for states to conduct planning and start-up activities.

Meanwhile, Democrats have reintroduced the Family and Medical Insurance Leave Act that would create a national paid leave program that would cover two-thirds of people’s wages for up to 60 days annually. With Republicans in control of Congress, however, there’s little chance it will pass.

Supporters say that many workers cannot afford to take unpaid leave and others aren’t eligible because they work for small employers. The law allows workers to take time off to care for a newborn or adopted child, or if they or a family member has a serious health condition. But it doesn’t apply to companies with fewer than 50 workers, and workers have to have worked for at least a year and logged at least 1,250 hours in the previous year to qualify for the benefit.

Only 13 percent of workers had access to paid family leave in 2013, according to the Department of Labor’s 2014 national compensation survey. Meanwhile, 59 percent were eligible for unpaid leave in 2012, according to DOL.

State experiences with paid family leave may provide guidance for a national paid family leave law. Since passage of the federal law, four states have enacted such programs.

Three of them — California, New Jersey and Rhode Island – fund the programs entirely by withholding employees’ wages. The programs are administered by states’ unemployment insurance agencies in conjunction with temporary disability insurance programs, according to human resources consultant Mercer. (Washington state has a paid leave program on the books but it has not been implemented because legislators haven’t approved funds.)

Rhode Island protects workers’ jobs if they take family leave, while the other two state programs do not. The federal law offers job protection for those working for large employers, but does not help those at small firms although other state laws may offer some protection.

California’s program is well established after more than a decade. It allows workers up to six weeks of leave annually at 55 percent of their weekly pay, up to a cap of $1,104 weekly in 2015.

When her children, now aged 5 and 2, were born, Allison Guevara took paid time off each time from her half-time job as a field representative for the American Federation of Teachers-affiliated union that represents librarians and lecturers at the University of California.

Guevara, 36, says that getting just 55 percent of her salary might have been problematic, but she was able to negotiate with her employer to use accrued vacation and sick time to make up the other 45 percent of her pay.

Altogether, she took off at least three months with pay for each baby. Her husband, who works for the city of Santa Cruz, was not so lucky. The law typically doesn’t apply to public sector employees.

“The time off was very necessary,” says Guevara. In addition to bonding with her kids, “breastfeeding was very difficult with my first one, it took eight weeks to get that going.”

Guevara stumbled upon the information about her paid leave options by accident.  That’s not surprising. A survey conducted last fall for the California Center for Research on Women and Families found that just 36 percent of Californians knew about the state’s paid leave program, a decline from three years earlier when 43 percent said they knew about the law.

“Those who know about it are those who disproportionately work for employers who already do it,” says Vicki Shabo, a vice president at the National Partnership for Women and Families. “That leaves out many lower-paid workers.”

California employers are generally positive about the paid family leave law, according to a study prepared for the U.S. Department of Labor last year. Ninety percent of employers in a 2010 survey said the law had either a positive effect on productivity, profit and morale, or it had no effect.

California, New Jersey and Rhode Island have built their programs around existing short-term paid disability program infrastructures; only five states have such disability programs in place, says Catherine Stamm, a senior associate at Mercer.

“It’s not as difficult or momentous for these employers,” Stamm says.

Under the Democrats’ bill, workers and employers would split the cost of the program, which would be administered by the Social Security administration.

But that’s a problem for small business owners, says Jack Mozloom, national media director for the National Federation of Independent Business, a trade group. Many of their members have fewer than 10 employees, Mozloom says, and if someone’s out on leave, it’s likely they have to hire a temporary worker or pay someone overtime to do the job.

Financing a paid leave program would “represent a real expense that some of them cannot absorb,” he says.

“When it’s mandated, it puts them in a hole.”

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.

The largest publicly run health plan in the nation, L.A. Care, will allow customers who do not have traditional bank accounts to pay their health insurance premiums with cash.

One in four Americans who were previously uninsured and eligible for federal insurance subsidies do not have a bank account, relying instead on pre-paid debit cards, money orders and cash to pay bills, according to a study by Jackson Hewitt Tax Service.

After advocates for low-income consumers raised concerns to the U.S. Department of Health and Human Services over how so-called ‘unbanked’ households would pay their monthly insurance premiums, the Obama administration ordered health plans to accept payment methods that didn’t require a credit card or checking account.

Starting Monday, customers of L.A. Care Covered, one of the health plans for sale on Covered California, the state’s insurance marketplace, can pay monthly premiums in cash at more than 680 locations, including 7-Eleven and Family Dollar Stores. At the register, customers scan a bar code sent to their smart phone and hand over their cash.   The payment posts to L.A. Care within 24 hours, and  the service is free to customers.

“It’s as quick as buying a Slurpee,” said Danny Shader, PayNearMe’s founder and CEO, the for-profit company that established the electronic cash transaction network.

L.A. Care, like most health insurers around the country, pays fees to Visa, MasterCard and banks to process debit and credit card transactions. Laura Jaramillo, Director of Commercial and Group Plan Operations at L.A. Care, said the health plan negotiated a similar surcharge to PayNearMe for cash payments.

“It should not increase our administrative costs,” Jaramillo said. L.A. Care estimates up to 25 percent of its marketplace customers mail in money orders each month. Now, members who don’t have a bank account can pay in cash, said Jaramillo, “instead of sending us money orders.”

Some low- and moderate-income households shun bank accounts, researchers find, because checking account and overdraft fees can wreak havoc on their precarious finances. These same households, however, rely heavily on cell phones—68 percent of unbanked households have mobile phones.

L.A. Care is the first health plan to use the PayNearMe network, although the company’s method of cash collection is already in use in other ways elsewhere: By Nebraska parents who owe child support, Pittsburg water customers and bike share riders in Philadelphia who can pay cash at local convenience stores to settle bills.

“What goes in is cash, and what comes out is an electronic payment,” said Shader. “We think everybody ought to do it.”

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