California spends less per person than any state on diabetes prevention programs, even as one in 12 California adults is estimated to suffer from the chronic disease, according to a new report from the California State Auditor.

Using only federal grants, California spent just 3 cents per person on diabetes prevention in the 2012-2013 fiscal year, compared to New York’s 42 cents per person in state and federal money that year, the report noted.

No state funding is available for diabetes prevention in California, although the Department of Public Health has solicited the federal grants for programs in some counties, according to the report. The audit takes the agency to task for not doing more.

A California Department of Public Health spokesman said no one was available for comment on Friday.

Because of declines in federal funding, California in 2012 shuttered nine regional centers devoted to reducing gestational diabetes. Now it has just website with information on the condition, which can affect nearly 10 percent of pregnancies.

But the state is not alone in underfunding prevention efforts, according to advocates.

“I know we’re on the bottom of the pile on this, but what money is out there for diabetes is just a pittance across the country, when you look at the size of the problem of diabetes,” said Michael Chae, executive director of the American Diabetes Association’s regional office in Oakland, Calif. “I’d say you could take this report for most large states and it would read similarly.”

Diabetes is a chronic disease that occurs when the body either cannot make enough insulin to control blood sugar (type 1) or cannot process insulin normally (type 2). Although diabetes can be controlled with medications and lifestyle changes including diet and exercise, the yearly health care and related costs of the disease have been estimated at $27.5 billion in California alone, according to the American Diabetes Association.

The state auditor’s report acknowledged that the state public health agency appropriately spends its federal dollars. It also recently received new federal grants for diabetes prevention efforts in four counties. But the report faulted the agency for not doing more to identify additional funding and for not expanding programs to other counties with high diabetes rates. Auditors were able to identify two additional federal grants totaling $1 million that the state could have applied for but did not.

The auditor described the public health agency’s stated goal of preventing diabetes in 380,000 people by 2022 as “lofty.” It concluded, however,  that the agency “will need to do more than it has been able to in the past with its limited funding.”

Nationwide, nearly 30 million Americans live with diabetes and about 1.7 million people are newly diagnosed each year, according to the U.S. Centers for Disease Control and Prevention. More than 2.3 million California adults report they have been diagnosed with diabetes and many others are considered to have the disease but do not know it. Still others are considered to be at high risk, or “prediabetic,” based on their blood sugar levels.

Chae and other diabetes advocates said they have tried repeatedly over the years to persuade  lawmakers to devote state money to diabetes prevention, to little avail.

It’s challenging to convince lawmakers and the public to devote more money to diabetes prevention, Chae said, because the disease is often unfairly characterized as a lifestyle problem caused by poor choices such as unhealthful eating and inadequate exercise. In addition, it progresses slowly, and symptoms are often invisible for years.

However, years of state reliance on federal grants alone has resulted in uncoordinated programs and staffers who come and go as the grants do, said Joan Werblun, a retired nurse and longtime advocate who helped found the Diabetes Coalition of California.

“When you get these grants, you’re so tied into the specifics of the grants, and most of the time, it’s about data collection on how the grant is going,” Werblun said. “That’s where the money’s going. The state’s very happy to point at their projects, but they’re very small and there’s no continuation when the money’s gone. What we need are more people in the communities doing the work.”

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

When Florida workers promoting President Barack Obama’s health law marketplace want instant feedback, they go to an online “heat map.” The map turns darker green where they’ve seen the most people and shows bright red dots for areas where enrollment is high.

“The map shows us where the holes are” and what communities need to be targeted next, said Lynn Thorp, regional director of the Health Planning Council of Southwest Florida. She hands out information about the health law’s marketplace at rodeos, farmers markets, hockey games —almost any place where people gather.

That mapping strategy is one reason why a Republican-controlled state like Florida, whose leaders have criticized the health law at every turn, is leading the nation in signing people up for private Obamacare health plans. With two weeks to go until the deadline for 2015 enrollment, Florida’s tally exceeds that of even Democratic-led California, which has embraced the law building its own online marketplace and has twice the population and uses three times as much federal funding for outreach.

“It’s surprising Florida has done as well compared to other states, and they will be looked at by folks who want to learn lessons to promote enrollment,” said Joel Ario, managing director for Manatt Health Solutions, a consulting firm, who worked for the administration setting up the exchanges soon after the law was passed.

As of mid-January, 1.27 million Floridians had enrolled in exchange plans, according to federal data, compared to 1.2 million Californians. Texas, which has 6 million more people than Florida, enrolled about 919,000 people in private plans. Both Florida and Texas have a 22 percent uninsured rate. California’s rate is 17 percent, according to latest Census data.

“It is truly ironic that Florida leads the nation in enrollment … with leadership that has actively opposed the law,” said Leah Barber-Heinz, executive director of Florida CHAIN, an advocacy group involved in outreach efforts. “It shows true commitment on the part of many and it portrays an extremely high need for affordable coverage.

There are other reasons cited for Florida’s robust enrollment —including intense competition among insurers in several big counties and the high degree of coordination among the nonprofits and community groups which received federal grants to sign people up.

Another key factor is the state’s decision not to expand Medicaid under the law. That’s left consumers with incomes above the federal poverty level of $11,600 per year with no coverage option other than to buy a private plan — with help from sliding-scale government subsidies.  About 800,000 Floridians who make less than the federal poverty level are shut out altogether because they make too little to qualify for subsidies for private plans, but too much to qualify for Medicaid. In Florida, adults with children qualify for Medicaid only if their income is below 34 percent of the poverty level. Childless adults are ineligible. Florida is one of 22 states that chose not to expand Medicaid after the U.S. Supreme Court made that provision optional for states.

In contrast, California expanded Medicaid to those making up to 138 percent of the poverty level, or $16,100 for an individual. The program has grown by 2.3 million people since fall of 2013, boosted partly by publicity for the online marketplace.

Covered California spokesman James Scullary said the exchange is not allowed to enroll people in private plans if their incomes fall between 100 and 138 percent of the federal poverty line, because they qualify for Medicaid.

Jon Urbanek, senior vice president of Florida Blue, the state’s dominant insurer, credits Florida’s strong enrollment in private plans, in part, to the state’s decision not to expand Medicaid.  He also points to the intense outreach by thousands of the carrier’s insurance agents. Florida Blue has conducted about 3,000 “town-hall” style meetings at its 18 retail centers. “We knew going in that this was going to be a face-to-face, get in the community type of action to build trust with people,” he said.

Florida has also gained from having an older population which is more likely to buy coverage than younger people, Ario said.  That population is centered in a handful of urban areas such as Miami, Orlando and Tampa, making them easier to target, he said.

In contrast, many uninsured Texans live outside the big markets of Dallas, Houston and San Antonio. Texas also has a higher proportion of Hispanics who have been more challenging to enroll because of language barriers.

Then there’s the unusual effort to coordinate outreach. John Gilbert, national field director for Enroll America, a nonprofit doing outreach in 10 states, said Florida has benefitted from having several large nonprofits with experience signing up children for Medicaid.  They have worked together closely  – helped in part by the heat map.

Thorp of the Southwest Florida Health Planning Council describes how every time she hands out Obamacare flyers at a fair, or counsels at a local library, the action get entered into a computer log, which immediately changes the heat map. That way, other outreach workers see where contacts have been made.

Data from actual enrollment in the Obamacare health plans is added using dots, although that information lags because it is controlled by the U.S. Department of Health and Human Services.

The darker the dots on the map, the more saturated the enrollments in that zip code. When users hover over a dot, it pulls up a box showing how many residents in that zip code received outreach, including how many got one-on-one help filling out an application.

“We can then make sure we are appropriately allocating resources,” said Melanie Hill, executive director of the Tampa-based Family Health Care Foundation, which devised the mapping tool. Her group is working with the University of South Florida, which received a $5.4 million federal grant to help people anywhere in the state enroll. In all, Florida nonprofits received $6.8 million in federal “navigator” grants.

Perhaps another, harder-to-measure factor is how advocates have been fired up by the opposition of many of the state’s political leaders, said Barber-Heinz of Florida CHAIN.

“Stakeholders that didn’t work together in the past are working together on this,” she said. “It drives us to work even harder.”

Barbara Feder Ostrov contributed to this story.

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

After the insurance exchanges set up under the Affordable Care Act first went live in late 2013, Lori Lomas started combing the website of Covered California on a hunt for good deals for her clients. Lomas is an agent at Feather Financial, in the Sierra Nevada mountain town of Quincy, California; she’s been selling health policies in rural communities for more than 20 years.

But in 2013, she noticed a troubling change that surprised her: For many clients, insurance options decreased.

“I just started running quotes for people,” Lomas says, “and began realizing that in [some] zip codes, the only thing that shows up is Anthem.”

In addition to Anthem Blue Cross, Blue Shield of California used to sell policies to individuals in every county in the state, according to the Department of Managed Health Care, one of California’s two teams of health insurance regulators. But by 2014’s open enrollment period, Blue Shield had pulled out of 250 zip codes throughout the state, including four entire counties: Alpine, Monterey, Sutter, and Yuba.

The gaps are particularly felt in the top third of the state, where thousands of residents now have only one choice of insurer if they want to buy a health plan on the exchange.

That’s in contrast, Lomas says, to other spots, like the San Francisco Bay Area, where she’s also been helping clients find policies on the state exchange. “I’d do it for them,” she says, “and, wow, there are six insurance companies or seven insurance companies. I think that was when I first realized how, truly, we were getting the shaft up here.”

Blue Shield of California declined an interview with NPR. But in a written statement, the company reported that it’s not selling in certain areas of California because it could not find enough health providers willing to accept a level of payment that would keep premiums low. According to the statement, the company also is not selling in areas where there is no contracted hospital within 15 miles.

Because of the broad changes in the individual health insurance market under the Affordable Care Act, “there is no accurate apples-to-apples comparison between the individual market in 2013 and the individual market in 2014 and beyond,” Blue Shield said, adding that “coverage areas were designed to meet regulatory guidance and with patient access to care in mind.”

Blue Shield of California is acting within the law, says Shana Alex Charles, director of health insurance studies at UCLA’s Center for Health Policy Research. She says Blue Shield could have offered to pay health care providers more. But, at the same time, she adds, insurance companies can’t be forced to operate at a loss.

“There’s no public charge that says they have to be in those zip codes,” she says. “If they determine that it’s not within their company’s best interests to remain there and sell their product there, then they won’t be there.”

That’s generally allowed under the federal health law — plans don’t have to sell throughout an entire state, for example. Consumer advocates say there is often a lack of doctors in rural areas, and agree that insurers shouldn’t sell plans where there isn’t a good network. But UCLA’s Charles says consumers lose when there are not many insurers to choose from.

“Competition breeds choice,” she says, “and people that are competing against each other, work to keep the consumer as happy as possible, so that the consumer will chose them. Competition in the marketplace is a good thing, in that it does keep companies, in some sense, honest.”

Two other companies — Assurant Health and Moda Health — are selling health policies in Northern California, but not on the state exchange. So if consumers choose to buy those plans, they can’t get the subsidies offered under the federal health law.

Assurant Health says it sells individual policies in every California zip code and covers out-of-state care. Moda Health just started selling individual policies in California for 2015.

This story is part of reporting partnership that includes Capital 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.

Consumers who received too much in federal tax credits when buying insurance on the health law’s marketplaces last year got a reprieve of sorts from the Internal Revenue Service this week. Although they still have to repay some or all of the excess subsidies, the IRS won’t ding them with a late payment penalty if they don’t repay it by the April 15 tax deadline.

“They’re trying to make this work,” says Timothy Jost, a law professor at Washington and Lee University who’s an expert on the health law.

Under the law, people with incomes between 100 and 400 percent of the federal poverty level ($11,670 to $46,680 for an individual in 2014) who did not have insurance through their job could qualify for tax credits to make premiums more affordable. They could elect to have these subsidies paid in advance directly to the insurance company, and many did. A typical tax credit was about $3,000 annually.

The amount people received was based on an estimate of their 2014 income. At tax time, that amount has to be reconciled against consumers’ actual income on IRS Form 8962. If consumers or the marketplace underestimated their 2014 income, they may have received too much in tax credits and have to pay back some or all of it.

How much people have to repay is based on their income and is capped at $2,500. People with incomes over 400 percent of the poverty line have to repay the entire amount, however.

This penalty reprieve only applies to the 2014 tax year. The IRS will allow people to repay what they owe on an installment basis. But be forewarned: Interest will continue to accrue until the balance is paid off.

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.

Medical homes are a simple, compelling idea: Give primary-care doctors resources to reduce preventable medical crises for diabetics, asthmatics and others with chronic illness — reducing hospital visits, improving lives and saving money.

But it’s not so easy in practice.

New reports show that two big experiments run by the health law’s innovation lab, known as the Center for Medicare & Medicaid Innovation, delivered mixed early results in enhancing primary care. The programs reduced expensive hospital visits in some cases but struggled to show net savings after accounting for their cost.

Consultants evaluated the first year’s results for the Comprehensive Primary Care Initiative, a four-year program in Colorado, New Jersey and several other states; and the Multi-Payer Advanced Primary Care Practice Demonstration, a three-year test in eight states including New York and Pennsylvania.

The CPC initiative cut costs by $168 per participating Medicare beneficiary, thanks largely to declines in hospital admissions and emergency visits, compared with results of practices not part of the initiative. Results were “more favorable than might be expected” in the test’s first year, said a report by Mathematica Policy Research.

But that wasn’t enough to cover the extra $240 per patient that HHS paid practices to hire extra nurses, improve electronic records, set up 24-hour call lines and make other adjustments. The goal was to identify high-risk patients, keep them on the right medicines and diets and steer them to lower-cost treatment.

“As a taxpayer — are we really making a difference?” said David Nash, dean of Thomas Jefferson University’s School of Population Health and an authority on improving care quality. “I can’t tell from this report.”

Nor was there a big change in quality-of-care indicators, such as follow-up visits after a hospital discharge and making sure patients got recommended diabetes tests. The reports gave little information on whether the added resources improved patients’ health, saying it was too soon to tell.

But those who believe medical homes, also known as patient-centered medical homes, are one answer to America’s expensive, uncoordinated health system found encouraging spots in the evaluation.

“The numbers don’t take your breath away,” said Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, a consortium of payers and caregivers. “But … the fact that the early results look as good as they do we take to be very good news.”

Almost all practices that signed up were still participating in the $322 million CPC test at the end of the first year. The complex tasks of identifying patients who could benefit from extra management and setting up care plans “proceeded relatively smoothly in the first program year,” Mathematica said.

Other payers including state Medicaid programs and commercial insurers joined Medicare in the CPC experiments to give primary doctors extra resources to coordinate care. Together they generated substantial extra revenue — $70,045 per clinician for a median practice — for about 500 participating primary practices.

“It is especially promising to see savings from reduced emergency department, hospitalization and readmission rates so soon,” the National Committee for Quality Assurance, which certifies medical homes, said in a prepared statement. Getting medical homes to their full potential “will likely require a longer commitment to the principles of coordinated care,” it said.

Another innovation-lab model, the multi-payer primary care demo, or MAPCP, did produce a small savings for Medicare — $4.2 million — after counting extra patient-management fees, according to an evaluation by RTI International.

MAPCP payers reimbursing primary doctors for care management also include state Medicaid programs and numerous insurance companies.

Although private insurers’ results aren’t included in the MAPCP evaluation, the report said some are unhappy with the program. Commercial insurers may be more impatient than government agencies to see care-coordination money for primary doctors pay off with lower overall costs.

“Payers are noticeably frustrated with the lack of data showing either a positive return on investment or an improvement in health outcomes for participants,” said the evaluation. “Multiple payers” have said they intend to quit Pennsylvania’s MAPCP test, it said.

Both MAPCP and the CPC initiative had start-up challenges involving training, communication and data management, the evaluations said.

Patrick Conway, HHS’ top innovation and quality officer, called the results “promising” in a blog post and said the cost reductions in the CPC program “were nearly enough” to cover agency fees paid to doctors for care management.

There has been little information released by HHS on another medical-home test, a three-year, $57 million experiment involving federally qualified health centers that ended last year.

The latest reports follow other research showing mediocre results for medical homes. A widely discussed study last year in the Journal of the American Medical Association found a medical-home pilot in Pennsylvania didn’t cut the overall cost of care.

But many of the medical-home experiments evaluated so far, including the Pennsylvania pilot, MAPCP and CPC, don’t include potent-enough incentives for doctors, say some reform advocates.

Rather than simply giving primary doctors extra funds to manage care, payers need to additionally reward them for cost and quality improvements and possibly penalize them for missing goals, they say. Similar incentives are found in accountable care organizations or bundled-payment arrangements that involve groups of caregivers working under a budget.

“If you change the economic incentives, you will change physicians’ practice behavior,” said Nash.

The CPC program intends to offer “shared savings” of cost efficiencies with primary physicians in its third year.

A medical-home program run by CareFirst BlueCross BlueShield in Maryland and the D.C. region that includes shared savings has more than paid for itself in total cost cutting while improving care, the company says.

After launching the arrangement for privately insured members, CareFirst got a $24 million grant from the HHS innovation lab to include Medicare patients. The company has hired outside evaluators to try to confirm its results, said Nielsen.

But she argues that cost savings aren’t the ultimate measure of medical-home success.

“If you put in incentives to save money you’re going to see practices save money,” she said. “But if all we do is save money and we don’t improve care, we’ll be cutting off our noses to spite our face.”

CPC and MAPCP are among dozens of experiments being run by HHS’ innovation center, which has a 10-year, $10 billion budget.

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

HHS proposes path to improve health technology and transform care

  Over five years after the global financial crisis, jobs are still scarcer than they used to be in the United States – but not everywhere! In true American spirit, for example, thousands of people looking for jobs – or better-paying jobs – have been trekking north and west to “men camps” in rugged states Continue Reading