Blog

DisAbility Rights Idaho (DRI) is a private non-profit corporation providing legal representation and a range of other advocacy services to Idahoans with disabilities. This advocacy includes informing policy makers of the effects of public policy proposals on people with disabilities.

Medicaid is an important source of medical care and home and community based services, which are essential to the independence, well being and, in many cases, the survival of Idahoans with disabilities.  We know from studies and reports obtained by the Idaho Department of Health and Welfare (IDHW) that there are thousands of Idahoans with disabilities and chronic health issues, who are in the Medicaid expansion population. This group includes many people with mental illness, and people with health problems which are episodic or variable over time.

The criteria for a disability related exemption is vague, inadequate and potentially harmful.

The application describes criteria for an exemption as “physically or intellectually unable to work (including behavioral health barriers)” is not sufficiently defined to ascertain whether any particular person with a health or disability issue will be exempt. When is a person with a disability “unable to work”?  Many people with health conditions are able to do work at some pace and at some level but cannot produce results at an economically viable level. Employment requires more than the ability to work. It requires attention to task, the ability to cooperate with coworkers, to follow instructions, to achieve a particular level of productivity, to attend regularly and punctually. Health conditions can make a person’s attendance unpredictable and their output highly variable. The ability to work and the ability to sustain employment for 20 hours per week are very different things. Until we know the method of making this determination we cannot evaluate the effect this standard will have on people with chronic health conditions. Individual determinations of the ability to work are a resource intensive process and if the decision is not to be arbitrary, it will require considerable time and expense. Mental illness is not a physical or intellectual impairment. We assume that the addition of the parenthetical phrase (including behavioral health barriers) is meant to address this problem created by the language of S1204. It does not.  If we have a rule that applies to “people unable to walk (including people who are hard of hearing)” it would be equally vague and unclear.  Without a definition of a “behavioral health barrier”, and how it relates to being “physically or intellectually unable to work” it is impossible to evaluate the effect of the criteria. The waiver application should not be approved until such effect can be evaluated, since it goes to the heart of whether the waiver will improve access to health care. IDHW should acknowledge the impossibility of implementing the statutory language and create an exemption based on disability.

The application does not reveal how the exemption process will apply to health conditions which are variable or episodic. A person with a mental illness may be able to work on some days or weeks and unable to work on other days or weeks. The same is true for people undergoing chemotherapy for cancer, people with chronic pain disorders, or inflammatory disorders, or a host of others. Most chronic health conditions  are variable and ability to sustain employment varies with the acuity of the condition.The application ignores this very substantial problem. Although IDHW may intend to clarify some of these issues in future rules, until we know how they are to be applied we cannot assess the effect on people with disabilities. The waiver application should not be approved until there is more clarity.

The process for determining whether an individual is “physically or intellectually unable to work” will be carried out by an eligibility worker “at application”. How eligibility workers will be qualified to make this determination “at application” is not explained. If the determination has not already been made by another agency, how can IDHW make this determination “at application”?

The proposal creates a powerful disincentive for people who are exempt from reporting due to a disability from seeking employment.

Once a person has established an exemption for being “physically or intellectually unable to work”, their Medicaid coverage is secure (as it should be). But if they attempt to work they risk being considered “able to work” even if the attempt eventually fails or if it involves great variation in hours worked. This creates the same work disincentive that has plagued Social Security Disability programs for decades. Social Security has partially addressed this disincentive by creating work incentive programs. This proposal has no such protections for disabled people hoping to work. Once an exemption is obtained, fear of loss of coverage will deter people from seeking employment. This is the exact opposite of the goal of the waiver.

There is also the psychological deterrent to employment. Once a person has claimed and proven that they are “unable to work” it is much more difficult to persuade them to try retraining or seek employment since they know their coverage is based on a complete inability to work. This is another reason to abandon the “unable to work” standard and embrace a “disability” based exemption.

The studies cited by this application for the proposition that employment and volunteerism improves health outcomes do not support the method chosen by this application.

While the Wadell/Burton paper cited in the application’s rationale, cites abundant support for an association between employment and better health, it acknowledges that there is no practical or ethical way to establish how much of the effect is due to employment causing better health outcomes versus better health status leading to more employment. The authors conclude that some of the effect is causal, but conceded that only a randomized controlled study could establish causality and, to date, none have been conducted. This is possibly because such a study would be unethical. Moreover, studies of this work/health association have shown that the effect disappears when the employment is low paying, stressful, has long hours or is unaccommodating of disability. In these cases, employment is associated with negative health outcomes. For low income people with disabilities, the jobs available tend to fit this description. The waiver proposal does not distinguish between types of employment or individual circumstances. Taken at face value, the Wadell/Burton study does not support the rationale for the waiver, much less the methodology that the waiver application proposes.

There is abundant evidence that denying health coverage to people significantly decreases their ability to seek, find, and retain employment.

The research supporting the idea that maintaining or obtaining health insurance coverage increases the chances of finding and retaining employment is well summarized in a paper published by Antoinesse and Garfield for the Kaiser Family Foundation:

“For example, in an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment, and over half of employed expansion enrollees reported that Medicaid enrollment made it easier to continue working. Similarly, a study on Medicaid expansion in Michigan found that 69% of enrollees who were working said they performed better at work once they got coverage, and 55% of enrollees who were out of work said the coverage made them better able to look for a job. A study on Montana’s Medicaid expansion found a substantial increase of 6 percentage points in labor force participation among low-income, non-disabled Montanans ages 18-64 following expansion, compared to a decline in labor force participation among higher-income Montanans. National research found increases in the share of individuals with disabilities reporting employment and decreases in the share reporting not working due to a disability in Medicaid expansion states following expansion implementation, with no corresponding trends observed in non-expansion states.”  https://www.kff.org/medicaid/issue-brief/the-relationship-between-work-and-health-findings-from-a-literature-review/ (footnotes omitted, emphasis added).

Similarly, research shows that providing health coverage increases the likelihood of volunteerism.

“Additional literature suggests that access to health insurance and care promotes volunteerism, finding that the expansion of Medicaid under the ACA was significantly associated with increased volunteerism among low-income adults.” (Ibid).

There is no literature finding that revoking or denying health coverage promotes employment or volunteerism, just the opposite. If denying coverage does not increase employment, then it cannot improve health outcomes, regardless of whether employment improves them or not.

The language concerning a two month “penalty” period of ineligibility makes no sense.

According to the draft application, a person who does not comply with the reporting requirements will lose coverage for two months as a penalty. However, if after two months they still do not provide proof of work hours, they are not readmitted to Medicaid. Also if they do provide proof of compliance, coverage resumes immediately. In other words a person’s Medicaid coverage is suspended for the period in which they cannot provide proof of work. The two month “penalty” is not a penalty and it makes no difference as to when Medicaid is reinstated. However, saying that there is a two month “penalty” will cause confusion to an already confusing process and may cause some people to refrain from seeking readmission to coverage. The application should remove the reference to a non-existent two month penalty.

The proposal does not include any services which would actually assist people in finding or retaining employment.

While the goal of the waiver is to improve health outcomes by increasing employment and income, nothing in the waiver actually provides any assistance with finding or retaining employment. In other states where Medicaid was expanded, positive employment related services did improve the level of employment for participants. Idaho’s proposal does not include any such services or assistance. It relies entirely on penalizing unemployed individuals with revocation of their medical coverage. People who are unemployed and already have no health insurance (the expansion population) already are motivated to seek employment in order to obtain coverage. If they haven’t been able to do so, denying access to Medicaid is unlikely to increase the incentive.

Having different reporting and verification periods will create more confusion and likely result in more loss of coverage by people who are employed. The proposal says that participants must report work (or volunteer, or education) hours monthly but provide verification every six months. These different reporting periods will cause confusion and likely lead to more reporting or verification errors. If the six month verification shows one month in which the person only averaged 18 hours/week and five months when they averaged 40 hour /week, will IDHW retroactively revoke coverage for the first week and make the person pay for medical bills in that month? If so, how does this promote either employment or health? If not, then what does the monthly reporting requirement accomplish? Reporting should be the same as verification requiring the same single report every six months.

Conclusion

This waiver application does not meet the criteria for an 1115 waiver.

• It will not improve access to health care or health care coverage. It can only exclude otherwise eligible people from coverage.
• It will not improve employment since it is based on revoking or denying coverage to unemployed people which has been shown to decrease the likelihood of obtaining employment.
• The standards for exemptions, the reporting and verification periods, and the language about “penalty” periods will increase confusion and increase the likelihood that people will lose coverage for errors in reporting or for misapplication of the standards for eligibility.
• The proposal creates the well known disincentive for exempt disabled people to seek work for fear of losing their exempt status, as was the case in Social Security programs for years.

Submitted by DisAbility Rights Idaho

Contact Dina Flores-Brewer, Executive Director

The Idaho Health Care Plan (IHCP) is a unique and innovative approach to extending opportunities for affordable health insurance coverage to some Idahoans in the health insurance gap, and to provide Medicaid coverage for Idahoans with certain diagnoses. IHCP requires two State Innovation Waivers, a Medicaid waiver under §1115 of the Social Security Act, and a waiver under §1332 of the Affordable Care Act.

The §1115 Waiver would allow Idaho to extend Medicaid coverage to people who have certain conditions which result in very high medical costs. Removing these people from the Idaho health insurance exchange and transferring their coverage to Medicaid will reduce costs and risk for the insurance carriers selling plans on the exchange. This in turn will result in lower premiums for insurance exchange customers, and also in lower federal premium assistance costs.

The §1332 Waiver would use some of those savings to extend premium assistance to households with incomes below the Federal Poverty Level making insurance affordable for about 30,000 Idahoans currently in the “gap”.

This helps Idahoans with disabilities in two ways:

1. People with one or more of the listed diagnoses (which include e.g., spinal cord injuries, cerebral palsy, several forms of cancer, Multiple Sclerosis, Osteogenesis Imperfecta) will have access to the full range of Medicaid covered services. Some of these people are currently without coverage, and some currently have a policy on the exchange. Medicaid covers long term services and supports (LTSS) which are not covered by private insurance policies. Even people who are currently covered by insurance will benefit from coverage of these services, and more comprehensive coverage from Medicaid.
2. Many people with disabilities, living below the FPL, who don’t have one of the listed conditions (e.g. people with mental illness) will at least have access to affordable health insurance on the exchange.

The IHCP is not a complete solution to the Idaho’s Health coverage problems. At least 20,000 Idahoans will still be left in the insurance gap. The IHCP does not provide premium assistance to people who do not have taxable income. Medicaid Expansion under the Affordable Care Act would provide much better coverage for Idahoans with disabilities, especially people with serious mental illness. It would also provide significant savings to the state of Idaho, not realized by the IHCP ( https://disabilityrightsidaho.org/idaho-health-plan-position-paper/ )

However, an estimated 5,000 Idahoans with serious health conditions would gain access to Medicaid coverage under the IHCP. Another 30,000 Idahoans living below the poverty level will have access to affordable coverage on the Idaho insurance exchange (Your Health Idaho). Many of these people also have disabilities and serious health conditions. These factors make the IHCP a significant step forward and a great improvement on the status quo. The IHCP is an opportunity to move Idaho in the right direction by making affordable health care available to Idahoans with low incomes, including many Idahoans with disabilities.

James R. Baugh, DisAbility Rights Idaho, 4477 Emerald St. Ste. B-100, Boise, ID 83706 phone (208)336-5353

Email: jbaugh@disabilityrightsidaho.org 

DisAbility Rights Idaho is Idaho’s Protection and Advocacy System for people with disabilities.  We provide advocacy, legal assistance and public policy analysis on behalf of Idahoans with disabilities.

We recognize that this waiver, in conjunction with a proposed §1332 Affordable Care Act, State Innovation Waiver, seeks to provide health care coverage for about 35,000 Idahoans who are currently without coverage, and to provide Medicaid eligibility for Idahoans with certain diagnoses. We support the waiver application as a significant first step in shrinking the coverage gap and providing an appropriate range of long term services and supports for some Idahoans with disabilities.

The last comprehensive attempt to quantify the number of Idahoans without access to affordable health coverage fond approximately 78,000 people in the insurance gap[note]Milliman, Inc. “2015 Financial Impact of the Medicaid Expansion on the Idaho Medicaid Budget Including State and County Cost Offsets.” Jan. 2016.[/note]. Several years of improved economic conditions and increased employment have probably substantially reduced that number. Current estimates using SNAP data and other sources suggest that the population is currently around 54,000. It is likely that the people who remain in the gap are even more disproportionately people with disabilities, and chronic health conditions, since these people are the least likely to benefit from increased job availability.

By far the best option for Idaho and Idahoans with disabilities is to take advantage of the enhanced federal match associated with the Affordable Care Act’s expansion provision to provide coverage for everyone in the gap. The Legislature has not been willing to do that so far. This proposal is a positive step in that direction.

We recognize that the selection of conditions for the §1115 waiver are based primarily on the impact that these conditions have on private insurance costs, and the impact that those costs have on premiums. Our concern however, is the impact on people with disabilities. We are very supportive of the changes released on November 22, 2017 to the list of eligible conditions to include, spinal cord injuries, and others.

The Application for the Complex Medical Condition waiver (CMC) will provide Medicaid coverage for some people with disabilities, that is, people with the listed conditions. This is obviously a significant benefit for those people currently in the “gap”, but it is also a significant benefit for people with disabilities who have an insurance policy on the state exchange. Private health insurance policies do not provide significant coverage for either long term care or for Home and Community Based Services (HCBS). Under the CMC waiver, both are covered. This will improve the risk pool for the exchange plans while providing coverage better suited to the needs of people with complex health conditions. Appropriate HCBS can delay or eliminate the need for long term care facility placements, and can prevent deterioration in health conditions, thereby reducing preventable hospitalizations, surgeries and other high cost treatments.

The CMC waiver does not include any coverage for people with serious mental illness (SMI).  We strongly recommend that the department include people with SMI.

Although their inclusion will increase the cost of the Medicaid program, those costs to the state are offset by savings in the Division of Behavioral Health, the State Catastrophic Care fund, the county indigent programs, and  the regional crisis centers. Indirectly, there will eventually be savings to local law enforcement, emergency departments, jails, first responders and the courts. Medicaid coverage for people with SMI is an overall fiscal benefit to Idaho.

It may be argued that the 1332 waiver will provide an opportunity for coverage for Idahoans with SMI who are “in the gap”. First, it is not clear how people without taxable income will qualify for the 1332 waiver. This is likely to be a problem for people with SMI. Second, private insurance plans will cover psychiatrist visits, prescription drugs, and some level of hospitalization. But private policies do not cover the range of services that have been demonstrated to be needed to support people with SMI in the community. Some of the most critical services such as psychiatric rehabilitation, intensive outpatient, peer supports, case management, partial care, and medication management, are covered by Medicaid, but not by insurance. Without some of these supportive services many people with SMI will not be able to comply with their psychiatrist’s appointments, or their medication regime. DBH provides some supports like ACT teams, but only for people who are already in crisis, not as ongoing supports.

It may be the case that the inclusion of people with SMI, makes it more difficult to establish the budget neutrality component of the application, if the Medicaid costs are not offset by reduced premium credits. We do not have the actuarial information needed to assess this issue. However, if it is possible to develop a waiver application which includes people with SMI, we should not let the opportunity pass by.

Idaho has a broken and fragmented mental health system which provides few services for people with SMI until they are in a serious crisis, posing a risk to themselves or others. We have little to offer these Idahoans unless they qualify for Idaho Medicaid. This approach to mental health has filled our jails and clogged our courts with people whose only offense is having inadequately treated mental illness. By failing to implement the expansion offered by the ACA, we have refused funding which could help Idaho make significant improvements to our system. If there is any way that we can use this waiver to improve mental health services for Idahoans with SMI, it would be a shame to let another opportunity pass by.

Submitted by James R. Baugh, Executive Director, DRI

Click the link below to open the article in another tab.

Community-based Rehabilitation Services Availability to Idaho Youth on Medicaid