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March 23 marks the two-year anniversary of the passage of the Affordable Care Act (ACA). While some Americans remain confused about what exactly this law really means for them and their families, and others disregard it as just another big political fight, the impact on many direct-care workers has been and will continue to be positive.

Because of the ACA, direct-care workers can no longer have their pre-existing conditions held against them by a health insurance company. They can keep their adult children covered under their employer-provided plan up to the age of 26. And those who get their insurance coverage from Medicare no longer have to pay out of pocket for preventive services.

The ACA has meant better health, better care, and in some cases, a few more dollars in the pockets of direct-care workers. For them, the ACA is not confusing or political — it’s real, and it’s about health and security.

More Health Benefits to Come

Millions of low-income women, including direct-care workers, will continue to benefit as ACA provisions are implemented between now and January 2014. These include:

• The expansion of community health centers that serve low-income communities.
• Expanded Medicaid coverage that will make health care affordable for hundreds of thousands of direct-care workers.
• Public subsidies that will help make health insurance premiums less expensive for those who don’t qualify for Medicaid.
• Free coverage for women’s preventive health care, including birth control.
• An end to discriminatory practices that make insurance premiums at least a third more expensive for women than for men.

Improving Direct-Care Jobs and Care

In addition to greatly expanding access to affordable coverage for direct-care workers, the ACA is improving the quality of direct-care jobs and care for elders and people with disabilities. For example:

• Six states have received three-year grants to develop core competencies, pilot training curricula, and test the viability of certification programs for personal and home care aides.
• More than 30 states developed comprehensive health care workforce development strategies using ACA grants.
• New transparency rules are making information about direct-care worker wages and benefits, staffing levels, and turnover in nursing homes available to the public.
• Training for certified nurse assistants includes new requirements for learning about dementia and abuse prevention.
• States have received additional funding to transition individuals out of nursing homes into their homes or in the community.
• Demonstration programs testing new models of care coordination — including new roles for direct-care workers — are being funded by an innovation center at the U.S. Department of Health and Human Services.

Expanded coverage, new training opportunities for direct care workers, and investments that build an aging and disability services infrastructure to better serve consumers — these are all positive outcomes of the ACA.

But there’s more work to do. Some in Congress have been chipping away at the law, and further budget cuts could undermine implementation, particularly the expansion of the Medicaid program. And the Supreme Court will hear challenges to the individual mandate and the Medicaid provisions in the ACA starting March 26, with a decision expected this summer.

Over the next 18 months, it will be important to remain vigilant, and to remind friends, family, and colleagues that the Affordable Care Act is already providing better care, at lower costs, to millions of Americans.

– by Carol Regan, PHI Government Affairs Director

Oregon's state capitol building

Contract negotiations between Oregon and the union representing home care workers there have stalled over a state proposal to substantially raise the eligibility requirements for aides to receive health insurance.

A bargaining team led by Oregon Gov. John Kitzhaber (D) wants to require home care aides that provide Medicaid-covered services to low-income elders and people with disabilities to work 130 hours a month for three consecutive months in order to qualify for health benefits. Currently, aides must work 80 hours for three straight months.

The increase in hours would cause 2,000 of the state’s 12,000 home care aides to lose their benefits, according to the Service Employees International Union (SEIU), which represents the aides.

In late December, negotiations between the state and the union reached an impasse, largely because of the insurance issue. Discussions between the two sides will re-open next month.

On January 18, a group of about 100 home care workers staged a protest against the cuts in Kitzhaber’s office.

The governor said that he respected home care workers and collective bargaining rights in general. “We will try to do all we can,” he said.

Budget Woes Cited

Kitzhaber’s bargaining team says that the cuts to home care workers’ benefits are necessary to help close a $300 million budget gap.

Oregon’s in-home care program has been the target of cuts before. On Jan. 1, home care workers saw their hours reduced by 5 percent, a move that saved the state $4 million.

But the SEIU and AARP Oregon say that the newly proposed benefits cuts go too far. The organizations have launched a media campaign asking Oregonians to speak out against the proposed cuts.

“It is extremely disappointing that Gov. Kitzhaber and his team are attempting to reduce benefits for low-wage workers just to save the state a few million dollars,” said PHI Government Affairs Director Carol Regan.

“Beyond that, this is bad fiscal policy,” Regan added. “Reducing low-wage workers’ access to health care will result in higher Medicaid enrollment and put a greater strain on emergency medical care in Oregon. These cuts will simply shift costs, not lower them.”

– by Matthew Ozga

The CLASS program dodged another potentially fatal blow last week when a Republican-led repeal attempt was defeated in the Senate.

Senator Jay Rockefeller (D-W.V.) blocked a request made by Sen. John Thune (R-S.D.) to advance a measure to repeal CLASS. Thune’s request needed unanimous consent to pass.

Additionally, AARP and 50 other aging and disability-rights groups sent a letter to House leaders last week urging them not to repeal the CLASS Act, the Affordable Care Act provision that would create the voluntary long-term care insurance program known as CLASS.

On October 20, PHI wrote that advocates of the CLASS Act remain hopeful that the program will eventually be implemented.

– by Matthew Ozga

HHS Secretary Kathleen Sebelius

U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius notified Congress on October 14 that her office would not be able to go forward with implementing the CLASS program because it would not be affordable or fiscally solvent over time.

However, just three days later the White House announced that it opposed repealing the federal voluntary long-term care insurance program.

While these mixed messages have reportedly left supporters of the CLASS program confused as to whether the program will ever be realized, they are accepting what administration officials have called a “misinterpretation” of the HHS announcement in private conversations with leading CLASS supporters.

Both LeadingAge President Larry Minnix, Jr. and Connie Garner, who heads up Advance CLASS, Inc., said that administration officials have told them that they do not intend to “kill the program” (subscription required).

Advocates are continuing to press the administration to carry on with the CLASS program. They are heartened by what was said in these private conversations, as well as by the former Centers for Medicare and Medicaid Services Chief Actuary Bob Yee‘s remarks, reported in Inside Health Policy, that “the administration has the tools to effectively implement CLASS within the parameters of the statute.”

“It may be possible to design a modest government-run voluntary long-term care insurance program that is financially viable,” said Howard Gleckman, a fellow at the Urban Institute, in a blog post. “That at least is the message buried in the reams of documents released by the Department of Health & Human Services last Friday when it abandoned CLASS.”

A provision in the Affordable Care Act (ACA) requires that the CLASS Act must be fiscally solvent for 75 years.

Not Fully Gone Yet

On October 19, Judy Feder, professor at the Georgetown University Public Policy Institute, said in a radio interview [begins at 36:21] that the administration’s “reluctance to stand up for [the CLASS program] is a disappointment.”

She added that CLASS “is not fully gone yet. It’s still hanging by a thread.”

A few days before the HHS announcement, 100 organizations — including PHI, AARP, National Multiple Sclerosis Society, and the Paralyzed Veterans of America — sent a letter to President Obama (pdf) about the value of the CLASS program to American families.

The letter concludes by saying, “Mr. President, Congress gave you authority to make changes to the design of CLASS to make it work. We fully expect the Administration to go forward and use that authority in implementing the law.”

Future of the Personal Care Assistant Workforce Advisory Panel Unknown

Also still unknown is the future of the Personal Care Assistant Workforce Advisory Panel, which was mandated by a provision in the ACA under the CLASS Office. The panel is responsible for advising Congress on the adequacy of the number of personal care aides, their wages and benefits, and access to their services, for both the CLASS and Medicaid programs.

Sebelius released an HHS report on the CLASS Act on October 14, which explains that 13 of the panel nominees have been accepted but have yet to meet.

PHI Director of Policy Research Dorie Seavey, who was appointed to the panel (pdf), said, “We hope that CLASS proceeds, but regardless, the issues that Congress intended the PCA Panel to address remain paramount. Our country must develop a personal care workforce panel that is able to meet the rapidly growing demand for in-home services and supports, and it would be a mistake to shelve the important work of this panel.”

– by Deane Beebe

PHI Michigan Senior Workforce Advocate Tameshia Bridges (at podium) with fellow MCH members

The Michigan Consumers for Healthcare (MCH) coalition held a press conference on October 11 to announce its support for a Senate bill to establish a state health insurance exchange and to offer recommendations on how to improve the legislation.

Under the Affordable Care Act (ACA), every state is required to create a health insurance exchange by 2014; the federal government is responsible for creating an exchange for states that do not comply with the law.

The MCH coalition, of which PHI Michigan is a member, is urging that the bill (SB 693) be modified to ensure that the proposed exchange’s governing board has a “dominant pro-consumer presence and culture,” and that there is “streamlined access to healthcare coverage for the state’s poor and underinsured.”

MCH is calling for the legislation’s proposed “opt-in” provision for Medicaid, MIChild, and other state-supported programs to be replaced with a “presumptive eligibility clause.”

“As the consumer voice for affordable, accessible, quality healthcare in our state, Michigan Consumers for Healthcare wants to see the proposed MIHealth Marketplace expand access, increase competition, reduce premium costs, be customer-service oriented and work for small businesses and individuals alike,” said MCH Director Don Hazaert.

Seamless Interaction with Medicaid Important to Direct-Care Workforce

Speaking at the press conference, PHI Michigan Senior Workforce Advocate Tameshia Bridges, a MCH board member, reported that 32 percent of Michigan’s 156,000 direct-care workers are uninsured (pdf). Direct-care workers in Michigan are three times more likely than the state’s general population to lack insurance.

“Seamless interaction between Medicaid and the proposed MIHealth Marketplace is important for the direct-care workforce,” Bridges said.

“Due to the low-wage and largely part-time work status of these workers, it is likely they will churn between Medicaid and private coverage, or that their families will get coverage from both sources,” she added.

Must Be a Reliable and Trusted Resource

The coalition also recommends that the bill’s language state that community organizations can serve as “navigators” for the exchange, and that specialized training be mandated for anyone serving as a navigator.

“Having credible and reliable people to explain health care options to both workers and employers has been shown to play an important role in boosting enrollment in other states with health care expansion programs,” Bridges said.

“The MIHealth marketplace must be seen as an accessible and trusted resource that direct-care workers can turn to for the health coverage options available to them, as well as for information that will help them determine the plan that best meets their needs.”

– by Deane Beebe

The Institute of Medicine (IOM) unveiled a report on October 7 that defines the “essential health benefits” (EHB) that should be offered by insurance companies selling health plans in the new state-based exchanges established under the Affordable Care Act.

The report included a strong recommendation supporting affordability as a guiding principle in designing benefit packages.

At the request of the Department of Health and Human Services (HHS), the IOM panel outlined criteria and methods for HHS to use to determine a minimum set of benefits for new health plans in the individual and small-group market starting in 2014. But the 300-plus page report did not lay out specific benefits.

“Costs must be taken into account,” the 18-member panel said. “Unless we are able to balance the cost with the breadth of benefits, we may never achieve the health care coverage envisioned in the Affordable Care Act.” The panel also said that HHS should initially define a “typical employer plan” based on what small employers offer, which often means less generous coverage.

“In many ways this is disappointing,” said Carol Regan, PHI director of government affairs. “While affordability is certainly a major factor for direct-care workers, this could lead to limited benefit packages that exclude necessary services. Given direct-care workers’ high on-the-job injury rates and high incidence of chronic health conditions, the last thing we want in 2014 is for them to remain underinsured without access to the care they need.”

The IOM report guides HHS through these five areas:

• defining the EHB and developing a target premium;
• public deliberation;
• monitoring the EHB;
• allowance for state variation; and
• updating the EHB.

The panel also recommends that HHS release the package for public comment by late spring 2012.

HHS Secretary Kathleen Sebelius said that she would review the panel’s report and hold a series of “listening sessions” across the country to get public comment. These hearings provide an opportunity for consumer advocates to voice their concerns and offer recommendations to HHS about services to include in the EHB package.

– by the PHI Policy group