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A new PHI analysis (pdf) on health care coverage for direct-care workers found that occupation, industry/setting of employment, and geographic region were key indicators of whether these frontline caregivers had coverage.

The new analysis, published in PHI Facts 4, Health Care Coverage for Direct Care Workers: 2009 Data Update (pdf), found that in 2009, of all the nation’s direct-care workers — nursing assistants, home health aides, and personal care aides:

• nearly 1 million (28 percent) were uninsured;
• nearly 20 percent received health coverage through Medicaid or other public insurance at some point during the year; and
• only 47 percent had employer-sponsored coverage — compared to 68 percent of U.S. workers generally.

Home Care Workers More Likely to Be Uninsured

While home care is the fastest-growing long-term care industry, home care aides employed by agencies are more likely to be uninsured and far less likely to have employer-sponsored coverage than direct-care workers who work in other eldercare and disability employment settings.

In 2009, of home care workers employed by agencies:

• 37 percent lacked health coverage, and
• only one-third had employer-sponsored insurance at some point during the year.

“Home care workers support the health and well-being of our rapidly growing aging population, yet these health care jobs are notorious for their lack of adequate health insurance despite very high rates of on-the-job injury,” said Dorie Seavey, Ph.D., PHI director of policy research.

“Without better health coverage for home care workers,” Seavey said, “our nation will have considerable difficulty attracting a stable, qualified workforce to support elders and people with disabilities who want to remain in their homes and communities.”

Coverage Varies by Regions

Health coverage for direct-care workers also varies considerably by region of the country.

In New England, for example, 13 percent of direct-care workers lacked coverage compared to 45 percent of direct-care workers in the West South Central region. These variations are largely due to state differences in Medicaid eligibility and the existence of collective bargaining agreements that secure health insurance for workers, PHI Facts 4 explains.

Health Reform: A Remedy

The new PHI analysis also provides the first assessment available of the likely impact of the Affordable Care Act on the direct-care workforce. When fully implemented in 2014, the act opens up the Medicaid program to all adults who earn less than 133 percent of the federal poverty level.

PHI finds that over 900,000 direct-care workers lived in households under 133 percent of the federal poverty level in 2009. As many as 40 percent of these workers were uninsured while 30 percent relied on public insurance, and another 30 percent had some kind of private insurance.

“The Affordable Care Act’s expansion of Medicaid eligibility to 133 percent will significantly reduce the number of uninsured direct-care workers,” said Carol Regan, PHI government affairs director.

“Since employer-sponsored insurance is either not available or not affordable for most direct-care workers, the importance of a strong, responsive public insurance system could not be more essential to determining the future of the eldercare/disabilities workforce.”

The complete analysis is available in PHI Facts 4, Health Care Coverage for Direct Care Workers: 2009 Data Update (pdf), which was made possible with support from The SCAN Foundation.

More information on health coverage and the direct-care workforce can also be found at PHI Health Care for Health Care Workers and in the PHI Chart Gallery.

– by Deane Beebe

The high costs of medical care led 41 percent of Americans to forgo necessary treatments or medications in 2010, according to the Commonwealth Fund‘s latest health insurance survey.

The biennial survey also found:

• 40 percent of respondents said they had struggled to pay medical bills in 2010.
• More than half (57 percent) of the respondents who had lost their medical coverage as a result of becoming unemployed remained uninsured. Only 25 percent of unemployed respondents found alternate coverage or were able to join their spouse’s insurance, and just 14 percent remained covered through COBRA.
• 32 percent spent more than 10 percent of their income on health care-related costs, including out-of-pocket expenses and premiums, up from 21 percent in 2001. Half of all respondents falling under the federal poverty line spent at least 10 percent of their incomes on health-related costs.
• 28 percent of all respondents were without insurance at some point during 2010. Extrapolated nationally, that percentage translates to 52 million uninsured Americans.

Overall, the report presents a picture of a country in which “health insurance became less affordable and health care more costly over the last decade — particularly for working families with modest incomes, who increasingly devoted a large share of their income to health care,” said Sara R. Collins, Ph.D., a vice president of the Commonwealth Fund and one of the authors of the survey.

PHI’s FACTS 3 analysis of the direct-care workforce (pdf) found that an estimated 900,000 direct-care workers went without health insurance coverage during 2009, and that the prevalence of employer-sponsored coverage has declined significantly.

Health Reform Will Reduce Burden

The Commonwealth Fund’s report points out that the Affordable Care Act will gradually relieve the burden of exorbitant health care costs and high uninsurance rates.

Under the health reform law, most Americans will be required to obtain health insurance by 2014, the year the law takes full effect. Americans with low and moderate incomes will be eligible for Medicaid or to purchase subsidized coverage from an insurance exchange.

“As the law’s provisions go into effect, the nation’s health insurance system will move from one in which 52 million adults suffered a time uninsured in 2010 to one in which few people will be without health insurance, even during a recession,” wrote the authors of the Commonwealth Fund report.

The Commonwealth Fund survey evaluated responses from more than 3,000 Americans between the ages of 19 and 64.

– by Matthew Ozga

President Obama signing health reform into law, March 23, 2010

March 23 marks the first anniversary of the passage of the health reform law.

The Patient Protection and Affordable Care Act (PPACA) and its companion legislation, the Health Care and Education Act of 2010, have already begun to make health coverage more accessible and change how health care is delivered in the United States.

Dozens of organizations throughout the nation, including the National Council on Aging, National Partnership for Women and Families, and Small Business Majority, are sponsoring events to celebrate the anniversary. The events will highlight the many protections afforded under health reform to people with low incomes, women, children, the elderly, people with pre-existing health conditions, and small businesses.

The “Moving Forward” events will be organized around the following themes:

• March 21: Protecting Small Business’s Care
• March 22: Protecting Seniors’ Care
• March 23: Protecting Patients’ Rights
• March 24: Protecting Women’s Care
• March 25: Protecting Young Adults’ Care

Details of the events will be released before each day. Contact Carol Regan, PHI director of government affairs and the Health Care for Health Care Workers campaign, for event information.

Health Reform and Direct-Care Workers

While the health reform law contains many general provisions that benefit direct-care workers, some of the items specifically address community-based long-term care services and support the direct-care workforce, including:

• Demonstration grants to develop and pilot competency-based training curricula for personal and home care aides.
• Establishment of a Personal Care Attendant Advisory Panel at the Department of Health and Human Services (HHS) as part of the creation of the new voluntary long-term care insurance program called the CLASS Act.
• Additional demonstration provisions to extend the Money Follows the Person rebalancing demonstration, Independence at Home demonstration program, and community-based collaborative care networks and transition programs (pdf).
• Grants to provide career ladders for new and incumbent workers and to help state develop comprehensive health care workforce development strategies (pdf).

Health Reform Law Resources

Visit the PHI Health Reform Resource Center and Health Care for Health Care Workers websites for more information about the law, including the Health Reform Fact Sheet series and a complete PHI summary of direct-care workforce and long-term care provisions (pdf).

– by Deane Beebe

Many governors are requesting a repeal of the Affordable Care Act‘s maintenance of effort (MOE) provisions, which prohibit states from making changes in Medicaid and State Children’s Health Insurance Program (CHIP) eligibility requirements until 2014 for adults and 2019 for children.

Consumer advocates across multiple constituencies, however, support the MOE provisions and are mobilizing to keep them in place and to counter other efforts to cut Medicaid services.

At The Consequences of Obamacare: Impact on Medicaid and State Health Care Reform, a hearing held by the House Energy and Commerce Committee on March 1, governors Haley Barbour (R-MS) and Gary Herbert (R-UT) requested that the federal government eliminate the MOE provisions.

In contrast, Governor Deval Patrick (D-MA) highlighted (pdf) the success of his state’s health care reform law, which is similar in many ways to the Affordable Care Act.

Mobilizing to Keep MOE Intact

Dozens of advocates, including PHI, voiced opposition to weakening the MOE provisions in a letter (pdf) to the U.S. House of Representatives.

During economic downturns like the current recession, Medicaid and CHIP play a critical role in maintaining access to health care and long-term services and supports for millions of children, elders, and people with disabilities, the advocates wrote. Although state budget problems are serious and warrant attention, advocates say that reducing access to critical services is the wrong response.

More information about why the MOE provisions are important to elders and people with disabilities has been provided by Families USA (pdf) and the Center for Budget and Policy Priorities (pdf).

Tackling Medicaid State Budget Cuts

Advocates are also working to scale back proposed state budget cuts to Medicaid services.

As many as 350 advocates from 48 states participated in the first of a series of webinars hosted by the Friday Morning Collaborative, a network of aging and disability advocates in which PHI participates, on February 25.

The webinar, State Budgets: Challenges and Opportunities for Home and Community Based Services (registration required), featured presentations by Judy Solomon, Center on Budget and Policy Priorities; Wendy Fox-Grage, AARP Public Policy Institute; Jerry Reilly, Eldercare Alliance–Washington State; and Diane Justice, National Academy for State Health Policy.

The Friday Morning Collaborative, which is led by the National Council on Aging and funded by The SCAN Foundation, just launched an online community to share resources (registration required). Medicaid cuts are a serious concern for aging and disability advocates and providers, especially as waiting lists for Medicaid home and community based long-term services and supports grow.

– by Gail MacInnes, PHI National Policy Analyst

This winter the Small Business Majority (SBM) sponsored a webinar in three regions on what the Affordable Care Act means for small business.

The educational program, “Your Bottom Line: What Healthcare Reform Means for Your Small Business,” focused on both federal and state provisions to help local small business owners understand how the law will affect them. The topics discussed included:

• Small business tax credits — who’s eligible for them and how to claim them
• State insurance exchanges
• High-risk pools
• Shared responsibility
• Cost containment

The webinar covered many of the broad outlines of the new law regarding cost containment. For example, the law will reduce the deficit by over $100 billion by 2020 and by $1.3 trillion by 2030. The webinar also explained where consumers will be able to get coverage (employer, Medicaid, Medicare, and the exchanges), as well as new insurance reforms.

SBM provided tools and resources for small businesses interested in learning more about the law, including health care statistics for small business.

Tax Credits for Small Business

The webinar further detailed the new and forthcoming tax credits for small businesses.

More than 4 million businesses are eligible for tax credits (83.7 percent of all businesses) with 1.2 million businesses eligible for the maximum credit.

Tax credits will be available on a sliding scale with up to 35 percent of premium expenses for 2010 to 2013, and up to 50 percent of premium expenses for any two years beginning in 2014.

– by Carol Regan, Director of PHI Government Affairs Office

Guest Commentary: Health Care Reform and Small Business

As a home care services provider who purchases health care coverage for my 150 employees, I was eager to participate in “Your Bottom Line: What Healthcare Reform Means for Your Small Business.” Like other long-term care providers, I am seeking information on how obtaining health care coverage for my employees will change.

While I am a supporter of “health care for health care workers,” I also worry about the cost of reform because we continue to face reimbursement cuts. Yet, with our insurance premiums out of control and unsustainable, something has to change.

Tax credits, exchanges, mandates, grandfathering…the list of new terminology goes on and on. The requirements and the unanswered questions of the new Affordable Care Act (ACA) are daunting.

The timeline for implementation begins now and stretches into 2018. With all of the talk of repealing the law — and a good deal of misinformation being disseminated about what the law is really all about — some may be inclined to just ignore it. But long-term care providers really need to prepare for what is coming and understand the opportunities and the challenges.

The Take Aways

For me, the major take aways from the webinar were a) the reminder of how extremely complex this act is, and b) that each and every one of us is affected by it.

We will need help understanding the language, making decisions for our businesses, and explaining our decisions to our employees. We will also need to understand the tax implications for our businesses and our employees. I was struck by how even with a specific timeline spanning from 2010 to 2018, many areas of the ACA are moving targets — subject to change.

I am concerned about the benefits that will be provided in the exchanges and the insurance choices offered under the exchanges. A major issue for long-term care providers like me is the affordability of health coverage for our employees over the next couple of years, until these exchanges are operational in 2014.

We have a lot of learning ahead and it remains to be seen what it all translates into. The devil is in the details.

I encourage other employers of long-term care services and supports to join me in learning about the new law and how it can benefit employers and our workers. I found the printed materials available on the SBM website helpful and encourage you to take a look.

Editor’s Note

More information about health care reform and how it impacts long-term care — including the fact sheet Small Business Benefits Available to Eldercare/Disability Services Employers (pdf) — is available on the PHI Health Care for Health Care Workers website.

Read the PHI’s case study on the Visiting Nurse Association of Indiana to learn how Linda invested considerable resources to strengthen her company’s leadership and communication, and created a supportive and respectable work environment.

The National Association of Insurance Commissioners (NAIC), the nation’s leading organization of insurance regulators, submitted to the U.S. Department of Health and Human Services (HHS) a set of recommended guidelines that would change the way insurance companies calculate their “medical-loss ratios,” making it more consumer friendly.

Under the Affordable Care Act, when insurance companies cover individuals and small groups, they will soon be required to maintain a medical-loss ratio of at least 80 to 20 (or 85 to 15 when insurers cover large groups). The majority of their revenue is to be spent on direct medical care, with the remaining 20 percent available to go toward administrative costs and profit.

Insurance companies that do not meet these minimums will be required to provide rebates to their customers.

The NAIC guidelines will not become official policy unless approved by HHS. However, they have preliminary approval from HHS Secretary Kathleen Sebelius, who said they are “reasonable [and] achievable for insurers, and will help to ensure insurance premiums [that] are, for the most part, supporting health benefits for consumers.”

Defining ‘Direct Medical Care’

The NAIC has been debating the specifics of exactly what constitutes “direct medical care” since March.

Insurance companies have pushed for a broad definition of the term — one that would include costs related to paying claims, signing up doctors, and running customer service call centers.

Consumer advocates, meanwhile, argued that those costs are all clearly administrative in nature. They pushed for a narrower definition of “direct medical care,” which they argue would benefit insurance policy holders.

The NAIC voted unanimously on October 21 to pass the more consumer-friendly set of recommendations governing the way that medical-loss ratios are calculated. Several last-minute amendments to the recommendations — including one that would have allowed broker commissions to be counted in the “direct medical care” portion of the ratio — were all defeated.

“This is such an important victory for consumers,” said Carol Regan, PHI Director of Government Affairs and the Health Care for Health Care Workers campaign. “It will ensure that insurance companies don’t waste premium dollars on items not related to medical services.”

“This will also benefit direct-care workers who have seen their benefits erode and premiums continually rise,” Regan said.

– by Matthew Ozga