Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups.

This article first appeared January 11, 2018 on Kaiser Health News.

By Phil Galewitz

The Trump administration early Thursday initiated a pivotal change in the Medicaid program, announcing that for the first time the federal government will allow states to test work requirements as a condition for coverage.

The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.

The document says who should be excluded from the new work requirements — including children and people being treated for opioid abuse — and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering or caring for a close relative.

“Medicaid needs to be more flexible so that states can best address the needs of this population,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said in a press release. “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”

Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.

Republicans have been pushing for the change since the Affordable Care Act added millions of so called “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138 percent of the federal poverty level (about $16,600 for an individual).

The Obama administration turned down several state requests to add a work requirement.

Ten states have applied for a federal waiver to add a work requirement — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.

An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments, said the agency may approve Kentucky’s request as early as Friday. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.

Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past three years after the state expanded eligibility under the ACA.

While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children — who make up nearly half of Medicaid enrollees — are excluded. So are the more than 10 million people on Medicaid because they have a disability.

More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative or are too sick to work.

Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.

But work requirements have strong public backing. About 70 percent of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year. (KHN is an editorially independent program of the foundation.)

The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.

In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children and elderly families.

CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”

“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.

Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.

“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.

Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.

The Affordable Care Act was trying to spur more spending on broader community initiatives, which have remained below 1% of operating costs at the hospitals.

This article first appeared January 08, 2018 on Kaiser Health News.

By Vickie Connor

The federal health law's efforts to get nonprofit hospitals to provide more community-wide benefits in exchange for their lucrative tax status has gotten off to a slow start, new research suggests. And some experts predict that a recent repeal of a key provision of the law could further strain the effort.

The increased emphasis on community-wide benefits was mandated by the Affordable Care Act. The health law required hospitals that meet federal tax standards to be nonprofits to perform a community health needs assessment (CHNA) every three years, followed by implementing a strategy to deal with issues confronting the community, such as preventing violence or lowering the rates of diabetes.

A study released Monday in the journal Health Affairs shows spending in these areas has remained relatively stagnant.

The research showed average spending by tax-exempt hospitals on community benefits in 2010 was 7.6 percent of total operating costs and bumped to 8.1 percent by 2014. But the bulk of that spending goes toward unreimbursed patient care, such as charity care. The ACA was trying to spur more spending on broader community initiatives, which have remained below 1 percent of operating costs at the hospitals.

"This is not easy for hospitals to do," said Gary Young, the study’s lead author and director of the Center for Health Policy and Healthcare Research at Northeastern University in Boston. "By tradition, by the nature of their resources, hospitals have not been oriented to prevention, they’ve been oriented to treatment."

New efforts by the Republican-led Congress may complicate the effort. The repeal last month of the ACA’s penalties for most people who don’t have health insurance has some experts questioning how some of these hospitals will be able to spend more on community benefits. The Congressional Budget Office has estimated that because of that change about 13 million people would give up their coverage by 2027, which could drive up costs for hospitals because there would be more uninsured patients.

"Anything that destabilizes the system and takes money out of the hospitals’ revenue stream is going to negatively impact them," said Gregory Tung, assistant professor at the University of Colorado’s School of Public Health. "It's tough for hospitals to be navigating that uncertainty."

Jill Horwitz, professor of law at UCLA who specializes in health issues, said hospitals have trouble planning community efforts when they are unsure of their finances.

"It's a very difficult context in which to operate a stable system," Horwitz said. "One day to the next, it's hard to know what the rules are, what the reimbursement is going to be and what kind of insurance your patients will have."

More than half of the hospitals in the United States are private, nonprofit organizations that are tax-exempt.

Lawrence Massa, president & CEO of the Minnesota Hospital Association, said the repeal of the ACA’s individual mandate penalties will change hospitals’ calculations.

"We certainly expect to see our uninsured rate go up as a result of repealing the individual mandate," he said, "so that’s going to have an opposite type of effect of where we thought the trend was going to be because we changed the rules in the middle of the game."

But it's too early to tell how hospitals will respond, according to Massa. Many are still grappling with the new requirements.

The ACA was enacted in 2010, but the provision requiring community-based action did not come into effect until the end of March 2012, and enrollment in ACA marketplace plans didn’t begin until 2014. Hospitals began early investments for assembling the needs assessments in 2011 and 2012, Massa said.

"In the later years, they’ll be using that data and comparing and reporting to the IRS how they’ve changed their community benefits spending as a result of those community health needs assessments," he said. "If everything stayed the way it was, I think we would know by 2020 whether this had the kind of impact that was anticipated."

Young and his research colleagues acknowledged in their study that "certainly, more time is needed" to assess the full impact of the law’s requirements on spending for community benefits.

Nonetheless, Young said, many hospitals lack the means to provide greater preventive care in the community.

They don’t have the necessary infrastructure, "the personnel or the knowledge to develop those strategies," he said. "They don't have the resources to necessarily invest in those areas."

Horwitz agreed. "If we’re going to require this high level of spending on community benefits and paying for patients who can’t afford care, something else has to give," she said.

The program is designed to educate high-risk opioid patients about pain management.

This article first appeared January 08, 2018 on Kaiser Health News.

By John Daley, Colorado Public Radio

Seven years ago, Robert Kerley, who makes his living as a truck driver, was loading drywall when a gust of wind knocked him off the trailer. Kerley fell 14 feet and hurt his back.

For pain, a series of doctors prescribed him a variety of opioids: Vicodin, Percocet and OxyContin.

In less than a year, the 45-year-old from Federal Heights, Colo., said he was hooked. "I spent most of my time high, laying on the couch, not doing nothing, falling asleep everywhere," he said.

Kerley lost weight. He lost his job. His relationships with his wife and kids suffered. He remembers when he hit rock bottom: One night hanging out in a friend's basement, he drank three beers, and the alcohol reacted with an opioid.

"I was taking so much morphine that I [experienced] respiratory arrest," Kerley said. "I stopped breathing."

An ambulance arrived, and EMTs administered the overdose reversal drug naloxone. Kerley was later hospitalized. As the father of a 12-year-old boy, he knew he needed to turn things around. That's when he signed up for Kaiser Permanente's integrated pain service. (Kaiser Health News is not affiliated with Kaiser Permanente.)

"After seven years of being on narcotics and in a spiral downhill, the only thing that pulled me out of it was going to this class," he said. "The only thing that pulled me out of it was doing and working the program that they ask you to work."

The program he refers to is an eight-week course, available to Kaiser Permanente members in Colorado for $100. It's designed to educate high-risk opioid patients about pain management. A recent class met at Kaiser's Rock Creek medical offices in Lafayette, Colo., a town east of Boulder. Will Gersch, a clinical pharmacy specialist, taught several patients learning to battle addiction the science behind prescription drugs.

"So, basically the overarching message here is the higher the dose of the opioids, the higher the risk," he told the group, as he jotted numbers on a whiteboard. "If you're over these two doses, that's a risk factor."

Upstairs, Gersch's colleague Amanda Bye, a clinical psychologist, highlighted a key element of the program: It's integrated. For patient care, there's a doctor, a clinical pharmacist, two mental health therapists, a physical therapist and a nurse — all on one floor. Patients can meet with this team, either all at once or in groups, but they do not have to deal with a series of referrals and appointments in different facilities. A spokesperson for Kaiser Permanente said researchers tracked more than 80 patients over the course of a year and found the group's emergency room visits decreased 25 percent. Inpatient admissions dropped 40 percent, and patients' opioid use went way down.

"We brought in all these specialists. We all know the up-to-date research of what's most effective in helping to manage pain," Bye said. "And that's how the program got started."

Bye said the team helps patients use alternatives like exercise, meditation, acupuncture and mindfulness. Some patients, though, do need to go to the chemical dependency unit for medication-assisted treatment for their opioid addiction. Benjamin Miller is an expert on integrated care with the national foundation Well Being Trust. Kaiser is on the right track, he said.

"The future of health care is integrated and, unfortunately, our history is very fragmented, and we're just now catching up to developing a system of care that meets the needs of people," he said.

Similar projects in California showed a reduction in the number of prescriptions and pills per patient, said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation. Her group released case studies of three programs similar to Kaiser's Colorado program. (Kaiser Health News produces California Healthline, an editorially independent publication of the California Health Care Foundation.)

"We've seen great success with these models that are integrating complementary therapy, physical therapy, behavioral health and medical care," Pfeifer said. A key strategy is to gradually decrease the amount of opioids a patient takes, rather than cut them off before they're ready. "It works so much better when the patients have access to these complementary therapies," she said. "And it works even better when those complementary therapies are part of an integrated team."

But it can be difficult to implement universally. One challenge is scale: Big systems like Kaiser Permanente have ample resources and enough patients to make the effort work. Another issue is payment. Some insurers won't pay for some alternative treatments; others have separate payment streams for different kinds of care.

"Frequently, behavioral health and medical health are paid for by entirely different systems," Pfeifer said.

The need for programs like Kaiser's is urgent. In 2016, a record 912 people died from an overdose in Colorado, according to data recently released by the state health department. Of those, 300 people died from an opioid overdose. Opioid use often leads to an addiction to heroin, which claimed another 228 lives last year in the state. Those two causes together now rival the number of deaths from car accidents in the state.

Colorado faces a severe shortage of treatment options. Making matters worse, the state's largest substance abuse treatment provider, Arapahoe House, decided to close as of Jan. 2.

Kaiser's integrated pain service has given some patients a second chance.

Robert Kerley, now a veteran of the program, recently shared his story with other patients. "I got my life back. I can sleep. I can eat. I can enjoy things," Kerley told them.

To cope with pain, Kerley starts his morning with stretching and a version of tai chi that he calls "my chi." He practices deep breathing. His advice to others suffering from pain or addiction?

"Do whatever it takes to walk away from it, like no matter what," Kerley said. "Trust me, it gets better. It gets 100 percent better than where you're at right now."

Better for Kerley means his relationships with his family have improved. And he's back at work, once again able to make a living as a truck driver.

They cite several reasons, including low public awareness, heavy workloads, fear that they won't be adequately paid and reluctance to treat drug-addicted people.

This article first appeared January 03, 2018 on Kaiser Health News.

By Anna Gorman

Gale Dunham, a pharmacist in Calistoga, Calif., knows the devastation the opioid epidemic has wrought, and she is glad the anti-overdose drug naloxone is becoming more accessible.

But so far, Dunham said, she has not taken advantage of a California law that allows pharmacists to dispense the medication to patients without a doctor’s prescription. She said she plans to take the training required at some point but has not yet seen much demand for the drug.

“I don’t think people who are heroin addicts or taking a lot of opioids think that they need it,” Dunham said. “Here, nobody comes and asks for it.”

In the three years since the California law took effect, pharmacists have been slow to dispense naloxone, which reverses the effects of an overdose. They cite several reasons, including low public awareness, heavy workloads, fear that they won’t be adequately paid and reluctance to treat drug-addicted people.

In 48 states and Washington, D.C., pharmacists have flexibility in supplying the drug without a prescription to patients, or to their friends or relatives, according to the National Alliance of State Pharmacy Associations. But as in California, pharmacists in many states, including Wisconsin and Kentucky, have divergent opinions about whether to dispense naloxone.

“The fact that we don’t have wider uptake … is a public health emergency in and of itself,” said Virginia Herold, executive officer of the California State Board of Pharmacy. She said both pharmacists and the public need to be better educated about the drug.

Pharmacists are uniquely positioned to identify those at risk and help save the lives of patients who overdose on opioids, said Talia Puzantian, a pharmacist and associate professor of clinical sciences at Keck Graduate Institute School of Pharmacy in Claremont, Calif.

“There’s a Starbucks on every corner. What else is on every corner? A pharmacy. So we are very accessible,” Puzantian told a group of pharmacy students recently as she trained them on providing naloxone to customers. “We are interfacing with patients who may be at risk. We can help reduce overdose deaths by expanding access to naloxone.”

Opioid overdoses killed 2,000 people in California and 15,000 nationwide in 2015.

Naloxone can be administered via nasal spray, injection or auto-injector. Prices for it vary widely, but insurers often cover it. The drug binds to opioid receptors, reversing the effect of opioids and helping someone who has overdosed to breathe again.

At least 26,500 overdoses were reversed from 1996 to 2014 because of naloxone administered by laypeople, according to the National Institute on Drug Abuse. Since then, the drug has become much more widely available among first responders, law enforcement officers and community groups. The drug is safe and doesn’t have serious side effects, apart from putting someone into immediate withdrawal, according to the institute.

Information on how many pharmacists are dispensing naloxone is limited, but one study last year showed access to the drug at retail pharmacies increased significantly from 2013 to 2015 from previously small numbers.

Interviews and available evidence from around the U.S. indicate that pharmacists have varying perspectives. In Kentucky, for example, one study found that 28 percent of pharmacists surveyed were not willing to dispense naloxone.

In Pennsylvania, pharmacists weren’t exactly lining up to hand out naloxone when the state passed a law in 2015 allowing them to do it, said Pat Epple, CEO of the Pennsylvania Pharmacists Association. She said there were some initial obstacles, including the cost of the drug and pharmacists’ limited awareness of the law. The association worked with state health officials to raise awareness of naloxone among patients and pharmacists and reduce the stigma of dispensing it, Epple said.

Wisconsin is also among the states that allow pharmacists to dispense naloxone. Sarah Sorum, a vice president at the Pharmacy Society of Wisconsin, said the state’s pharmacists want to expand their public health role and help curb the opioid epidemic. But reimbursement has been a challenge, she said.

Not all health plans across the nation cover the full cost of the drug, and pharmacists also are concerned about getting paid for the time it takes to counsel patients or their relatives.

California and other states require pharmacists to undergo training before they can dispense naloxone to patients who don’t have a doctor’s prescription. Puzantian and others say that in California not enough pharmacists are getting the training, which can be taken online or in person and can cost a few hundred dollars.

So far, the California State Board of Pharmacy has trained between 450 and 500 pharmacists, and the membership-based California Pharmacists Association has added an additional 170. Other smaller organizations offer the naloxone training, according to the association. There are about 28,000 licensed pharmacists in the state.

Once trained, California pharmacists who provide naloxone must screen patients to find out if they have a history of opioid use. They also must counsel people requesting the drug on how to prevent, recognize and respond to an overdose.

Some say training requirements are an unnecessary barrier, especially given the high level of education already required to become a pharmacist.

Some of the bigger pharmacy chains, including CVS, Rite Aid and Walgreens, have made the drug available without a prescription in the states that allow it. Walgreens has announced that it would stock the nasal spray version of naloxone at all of its pharmacies. It said it offers the drug in 45 states without requiring the patient to have a prescription.

Peter Lurie, president of the Center for Science in the Public Interest, said not every pharmacy has to dispense naloxone for people to have access to it. “But the greater the number of dispensing pharmacies the better,” he said, adding that it is “especially important in more sparsely populated areas.”

Corey Davis, deputy director of the Network for Public Health Law, said making naloxone available over the counter would also increase access, since people could buy it off the shelf without talking to a pharmacist.

Bryan Koschak, a community pharmacist at Shopko in Redding, Calif., said people should go to a hospital or doctor’s office for naloxone. “I am not champing at the bit to do it,” he said. “It is one more thing on my plate that I would have to do.”

Michael Creason, a pharmacist in San Diego expressed a different view. He did the training after his employer, CVS, required it. He said pharmacies are a great vehicle for expanding access to naloxone because patients often develop a rapport with their pharmacists and feel comfortable asking for it.

Pharmacy associations should educate their members about the laws that allow naloxone to be provided without a doctor’s prescription and persuade more of them to provide the drug to customers who need it, Lurie said. Others say more pharmacists should put up signs to make customers aware that naloxone is available in their shops.

The California Pharmacists Association said it is trying to raise awareness through newsletters and emails to pharmacists in the state. “We want to see every pharmacy be able to furnish naloxone and every person at risk have access to it,” said Jon Roth, the association’s CEO.

The state’s pharmacy schools also include the training in their curriculum. One day recently, Puzantian explained to a classroom full of pharmacy students that naloxone is effective, safe and can prevent death.

“You can’t get a dead addict into recovery,” she told the students. Drug users “might have multiple overdoses, but each overdose reversal is a chance for them to get into recovery.”