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News

Jun 23, 2023

by and

An expert in policy advocacy and coalition building, Chaer has dedicated her career to helping people meet their basic needs and expanding economic opportunity. She serves on the executive committee of the All Families Deserve a Chance (AFDC) coalition. Staff page ›

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2023 Legislative Review, Part 2: Medical Debt and Health Care

by and | Jun 23, 2023

Equity work, Family Economic Security, Health, Immigration, Legislative Updates, Research and Policy Analysis

The high cost of health care leaves too many Coloradans with bills they cannot afford to pay — and can even deter people from seeking needed medical care in the first place. One in eight Coloradans have medical debt in collections[i], and low-income people and communities of color are disproportionately impacted.

In previous years, CCLP led groundbreaking legislation to reform the hospital bill collections process, HB21-1198. This law requires all Colorado hospitals to provide low-income hospital patients with discounts and affordable payment plans, among other patient protections. (Learn more about Colorado’s new Hospital Discounted Care law at cohealth.co/hospitaldiscounts.)

This year, five bills – including one of CCLP’s priority bills – addressed medical bills and medical debt. CCLP led efforts on HB23-1126, which stops medical debt from being included on credit reports, except in very limited circumstances. Bad credit reports not only hurt one’s ability to qualify for affordable credit, but they can also affect access to rental housing, employment, insurance, and more. The State Attorney General’s Office led the effort of SB23-093, which strengthens consumer protections in the medical billing and collections processes, including limiting interest on medical debt to 3%.

A hospital Medical Price Transparency bill, SB23-252, continues to build on federal legislation which requires hospitals to give online pricing information for consumers to compare treatment costs between hospitals prior to treatment and incurring costs. CCLP supported previous state legislation, HB22-1285, which prohibited certain debt collection practices if the hospital was not in compliance with price transparency requirements. State law will require hospitals to include costs, negotiated rates, and discounted cash prices.

 

New solutions for rising costs

Colorado Consumer Health Initiative also led a coalition which included CCLP in limiting Hospital Facility fees, HB23-1215. Many Coloradans are surprised to get a medical bill with an unexpected facility fee, which can be hundreds or even thousands of dollars and is frequently not covered by insurance. Strongly opposed by the Colorado Hospital Association, the bill was narrowed, but passed as a prohibition of facility fees on outpatient preventative care, a requirement to disclose and post the fee, to list the fee separately on the bill, and for Colorado Department of Health Care Policy & Financing (HCPF) to produce a report on the impact of facilities fees in Colorado.

Another contributor to high medical costs can be the high cost of certain prescription drugs. While many contribute greatly to maintaining health and fighting disease, and may reduce potential costs of hospitalizations, many critical drugs are priced excessively. CCLP advocated for the creation of The Prescription Drug Affordability Review Board with SB21-175. It authorized the board to review up to 12 drugs to assess price and to establish upper payment limits on them. With this year’s HB23-1225 the 12-drug limit was removed, in large part because one drug can have multiple versions.

Another major update to HB19-1320, which was originated by CCLP, was the community benefit for non-profit hospitals. Taxpayers invest hundreds of millions of dollars in Colorado nonprofit hospitals through tax exemptions.  Nonprofit hospitals receive these very substantial financial benefits on the condition that they invest in services and activities to help improve health outcomes in the communities they serve. HB23-1243, Hospital Community Benefit, strengthens the hospitals’ reporting requirements, HCPF’s enforcement mechanisms, and, most importantly, the process by which communities are engaged to have a voice in determining how these investments are spent. Strengthening the community engagement aspect of these investments is one way of ensuring that there is a direct connection between the significant and wide-ranging needs in our communities, and the investments that hospitals provide.

 

Protecting access for Coloradans

This session, CCLP supported two important bills regarding access to health care. HB23-1300, led by Colorado Children’s Campaign, directs HCPF to conduct a study of continuous medical coverage by January 1, 2026, including preparing documents needed to seek authorization from the federal government. In addition, by April 1, 2024, HCPF is required to seek federal authorization to provide continuous coverage for Colorado children under 3 years of age, regardless of immigration status. HCPF would also seek authorization for 12 months of coverage for adults being released from the state’s Department of Corrections facilities.

CCLP researched and advocated for including these provisions. CCLP also testified in favor of a Division of Insurance bill as a voice for consumers, HB23-1303, which would protect Coloradans from insolvent insurers. Currently, two Colorado Health Maintenance Organizations (HMOs) have been on the brink of insolvency which would have had ripple effects across the industry. HB23-1303 would require all HMOs in Colorado to contribute to the fund to insure their solvency.

Another success from this year included a Reproductive Rights package in the form of SB23-188, SB23-189, SB23-190. Since the passage of these bills in mid-April, Colorado has become a haven for abortion care. The package further expanded protections around reproductive health care for patients and providers, including gender-affirming care for transgendered people; increased access to reproductive health care by requiring certain health insurance carriers to cover this type of care; and ended deceptive trade practices in pregnancy-related services, such as collusive marketing and advertisements by “faux”/crisis pregnancy clinics. By signing these bills into law, Colorado continues to protect the rights of individuals to choose what is best for their own body.

 

Immigrant access to public benefits

Last summer, CCLP brought to the attention of the CDHS and HCPF that Colorado’s prohibition on beneficiaries sponsoring family members or other individuals to immigrate to the U.S. was in violation of federal law. The state agencies agreed, and CDHS introduced HB23-1117, Affidavit of Support Eligibility Public Benefits. CCLP supported the bill, which passed and was signed into law, making the state compliant with the federal statute.

 

Behavioral health

The weight, pain, and damage of mental health difficulties are affecting a growing number of Coloradans and their families. Access to services is limited by the increased need for such services, a workforce that is burned out, and broken internal systems. CCLP supported SB23-174, Expanding Access to Behavioral Health Services for Colorado Kids, which removes the prerequisite of needing a formal behavioral health diagnosis for behavioral health services. This bill opens access to a wide array of services, such as psychotherapy and services related to case management, prevention, education, and outreach. This policy applies to thousands of kids across the state covered by Medicaid and the School Health Services Program. By eliminating the diagnosis requirement more Colorado kids and their families can access affordable, early, prevention-focused services before a crisis occurs.

HB23-1007, Higher Education Crisis and Suicide Prevention bill requires crisis and suicide prevention numbers to be printed on student ids for higher education students. This simple action could provide convenient information and a lifeline at the right time while in a mental health crisis.

The criminal justice system, prisons, and jail are too often the mental health providers of first resort. This has been long known and bemoaned. HB23-1153 requires research on the feasibility of creating a system to support individuals with serious mental health illness through a collaboration between Colorado’s behavioral health and judicial systems.

 

As we like to point out at CCLP, the passage of a bill into law is only the beginning, but not the end of the work that needs to be done. Rulemaking and public input opportunities, outreach and public information, and implementation are the steps which help these policies take form, giving them the power to better the lives of Coloradans experiencing poverty. Even as that timeline plays out this year, work has already begun through our various organizational partnerships and coalitions on our 2024 legislative agenda.

 

[i] https://kdvr.com/news/data/study-1-in-8-coloradans-is-in-medical-debt/

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

Health First Colorado is the name given to Colorado’s Medicaid program. Medicaid provides public, low-cost health insurance to qualifying adults and children. It is an entitlement program funded by the federal, state, and county governments and is administered by counties in Colorado. Those who are required to pay must pay a small co-pay when receiving certain health care services.

State Department: Department of Health Care Policy and Financing

Eligibility: Most adults 18 to 64 are eligible for Medicaid in Colorado if their household income is at or below 133% of the federal poverty limit (FPL). Pregnant women are eligible with incomes of up to 195% FPL, while children under 18 may be eligible if the live in a household with income at or below 142% FPL. Some adults over 65 may also be eligible for Medicaid.

Program Benefits: Through Medicaid, low-income Coloradans are eligible for a range of health care services at little to not cost. Services provided include doctors visits, prescription drugs, mental health services, and dental care. Co-pays for certain individuals may be needed for certain services.

Program Funding and Access: Colorado funds our Medicaid program through state and federal dollars. Medicaid is an entitlement program, which means that all who are eligible for Medicaid can access the program, regardless of the funding level in a given year. This does not mean that it is always easy to access Medicaid, even when eligible. And since the program is administered by counties, funding levels for county staff and other administrative roles can make it easier or harder for Coloradans to access the program. On top of this, not all medical providers accept Medicaid which limits the ability of Coloradans to seek health services even if enrolled, such as if the nearest provider is a 2+ hour drive away.

Note: This data is from before the pandemic and does not reflect changes in enrollment rules during the COVID-19 pandemic and public health emergency.

Statewide Program Access 2015-19: Over the study period of this report, an average of 89.0% of the population at or below 133% of FPL (i.e., the population who is likely to be eligible for Medicaid) were enrolled in Medicaid in Colorado.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

The Supplemental Nutrition Assistance Program or SNAP helps low-income Coloradans purchase food by providing individuals and families with a monthly cash benefit that can be used to buy certain foods. SNAP is an entitlement program that is funded by the federal and state governments and administered by counties in Colorado.

State Department: Department of Human Services

Eligibility: Currently, Coloradans qualify for SNAP if they have incomes below 200% FPL, are unemployed or work part-time or receive other forms of assistance such as TANF, among other eligibility criteria. Income eligibility for SNAP was different during the study period of this report than today—it was 130% FPL back in 2019 for example. The US Department of Agriculture uses the population at or below 125% FPL when calculating the Program Access Index (or PAI) for SNAP. We follow this practice in our analysis despite Colorado currently having a higher income eligibility threshold.

Program Benefits: SNAP participants receive a monthly SNAP benefit that is determined by the number of people in their household and their income. Benefit amounts decrease as income increases, helping households avoid a sudden loss of SNAP when their incomes increase, even by a minor amount. Benefits are provided to an Electronic Benefit Transfer (EBT) card that can be used to purchase eligible food items, such as fruits and vegetables; meat, poultry, and fish; dairy products; and breads and cereals. Other items, such as foods that are hot at their point of sale, are not allowable purchases under current SNAP rules.

Program Funding and Access: SNAP, like Medicaid, is a federal entitlement program. This means that Colorado must serve any Coloradan who is eligible for the program. As such, funding should not be a limit to how many Coloradans can be served by the program. However, funding for administration of SNAP at the state and county level can limit the ability of county human service departments to enroll those who are eligible. Other program rules and administrative barriers can make it difficult for Coloradans to receive the benefits they are legally entitled to receive.

Statewide Program Access 2015-19: Over the study period of this report, an average of 61.1% of the population at or below 125% of FPL (i.e., the population who is likely to be eligible for SNAP) were enrolled.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children, also know as WIC, provides healthcare and nutritional support to low-income Coloradans who are pregnant, recently pregnant, breastfeeding, and to children under 5 who are nutritionally at risk based on a nutrition assessment.

State Department: Department of Public Health and Environment

Eligibility: To participate in WIC you must be pregnant, pregnant in the last six months, breastfeeding a baby under 1 year of age, or a child under the age of 5. Coloradans do not need to be U.S. citizens to be eligible for WIC. In terms of income, households cannot have incomes that exceed 185% FPL. Families who are enrolled in SNAP, TANF, Food Distribution Program on Indian Reservations (FDPIR), or Medicaid are automatically eligible for WIC. Regardless of gender, any parents, foster parents, or caregivers are able to apply for and use WIC services for eligible children.

Program Benefits: WIC provides a range of services to young children and their parents. These include funds to purchase healthy, fresh foods; breastfeeding support; personalized nutrition education and shopping tips; and referrals to health care and other services participants may be eligible for.

Program Funding and Access: WIC is funded by the US Department of Agriculture. The state uses these federal funds to contract with local providers, known as WIC Clinics. In most cases, these are county public health agencies, but that is not the case in all Colorado counties. Some WIC Clinics cover multiple counties, while others are served by multiple clinics. Private non-profit providers are also eligible to be selected as a WIC Clinic.

Statewide Program Access 2015-17: Between 2015 and 2017, an average of 52.2% of the population eligible for WIC were enrolled in the program in Colorado.

Financial Security:
Colorado Works

Colorado Works is the name given to Colorado’s program for Temporary Assistance to Needy Families or TANF. It is an employment program that supports families with dependent children on their path to self-sufficiency. Participants can receive cash assistance, schooling, workforce development and skills training depending on the services available in their county.

State Department: Department of Human Services

Eligibility: In general, Coloradans are eligible to enroll in TANF if they are a resident of Colorado, have one or more children under the age of 18 or pregnant, and have very low or no income. For example, to be eligible to receive a basic cash assistance grant through TANF, a single-parent of one child could not earn more than $331 per month, with some exclusions—and would only receive $440 per month (as of 2022). That said, there are other services provided by counties through TANF that those with incomes as high as $75,000 may be eligible for. In addition to these, participants in TANF are required to work or be pursuing an eligible “work activity” or work-related activity. Any eligible individual can only receive assistance if they have not previously been enrolled in TANF for a cumulative amount of time of more than 60 months—this is a lifetime limit that does not reset. Counties may have additional requirements and offer benefits that are not available in other counties in Colorado.

Program Benefits:  While the exact benefits that one is eligible for under TANF can vary, all qualified participants are eligible to receive a monthly cash payment, call basic cash assistance. Other than cash assistance, counties are have a lot of choice in how to use their TANF funding; generally a use of TANF funds is appropriate so long as it advances one or more of the four purposes of the program: (1) provide assistance to needy families so that children can be cared for in their own homes or in the homes of their relatives; (2) end the dependence of needy families on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families.

It is important to note that those eligible for TANF are also eligible for many of the other programs we’ve included in this report, such as SNAP, Medicaid, and CCCAP.

Program Funding and Access: Colorado funds its TANF program through funds received from the federal government through the Temporary Assistance for Needy Families block grant. Most of the federal funds are allocated by the state to counties, which are required to provide a 20% match of state funding. Federal and state rules allow the state and counties to retain a portion of unspent funds in a TANF reserve.

Statewide Program Access 2015-19: Over the study period of this report, an average of 50.7% of the population at or below 100% of FPL (i.e., the population who is likely to be eligible for TANF) were enrolled in TANF in Colorado.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

The Colorado Child Care Assistance Program provides child care assistance to low-income families and caregivers living in Colorado in the form of reduced payments for child care. It is a program funded by the federal, state, and county governments and is administered by counties in Colorado. The share owed by parents/caregivers is determined on a sliding scale based on the family’s income.

State Department: Department of Early Childhood Education

Eligibility: Counties set eligibility for families separately, but must serve families with incomes at or below 185% of the Federal Poverty Limit. Families accepted to the program are no longer eligible once their income exceeds 85% of the state median income. Parents or caregivers must be employed, searching for work, or engaged in another approved activity to be eligible for CCCAP. Parents and caregivers enrolled in Colorado Works (Temporary Assistance to Needy Families or TANF) or in the child welfare system are also eligible to participate in CCCAP. Generally, CCCAP serves families with children under 13, although children as old as 19 may be eligible under certain circumstances.

Program Benefits: If a family is eligible for CCCAP and has income, they may likely have to pay a portion of their child’s or children’s child care costs each month. The amount that families owe is based on their gross income, number of household members, and the number of children in child care in the household. As such, households tend not to experience a benefit cliff with CCCAP when they see their incomes increase

Program Funding and Access: Colorado funds the CCCAP program using federal dollars it receives from the Child Care and Development Block Grant program. The state allocates federal and state funds to counties using a formula that takes into account factors like current caseloads and the number of eligible residents. Assistance is available until the county’s funds are spent, so the number of families that can be served is often a function of how much funding is available and the income and composition of the household that applies. It is not uncommon for counties to overspend or underspend their allocations of funds. The state reallocates unspent funds from counties who underspent to those who overspent. While underspending could indicate a problem with the way a county administers its CCCAP program, it could just as likely be a sign that there are few providers in the county who participate in CCCAP—or a lack of providers generally.

Statewide Program Access 2015-19: Over the study period of this report, an average of 10.8% of the population at or below 165% of FPL and younger than age 13 (i.e., the population who is likely to be eligible for CCCAP) were enrolled in CCCAP.

Housing:
HUD rental assistance programs

The US Department of Housing and Urban Development (HUD) has three housing assistance programs that we look at together: Housing Choice Vouchers (Section 8), Project-based Section 8, and Public Housing. In Colorado, these programs provided assistance to over 90% of the households who received federal housing assistance from all HUD programs. Through federally funded, local or regional public housing agencies (PHAs) are the agencies that administer these programs, through not all are available in all counties. These are not the only programs available in Colorado that assist households afford the cost of housing, such as units funded through federal and state tax credit programs.

State Department: Department of Local Affairs

Eligibility: Generally, households with incomes under 50% of the area median income (AMI) of the county they live in are eligible for these rental assistance programs, although PHAs have discretion to select households with incomes at higher percentages of AMI. That said, HUD requires that 75% of new vouchers issued through the Housing Choice Voucher/Section 8 program in a given year are targeted to households with incomes at or below 30% of AMI. PHAs are also able to create criteria that give priority to certain types of households who are on waiting lists for these programs.

Program Benefits: These rental assistance programs help households afford the cost of housing by reducing their housing costs to around 30% of their household income. In the case of the Housing Choice Voucher program, the PHA pays the voucher holder’s landlord the remaining portion of the rent.

Program Funding and Access: Funding and access are both challenges for these rental assistance programs. In addition to limitations on the number of public housing units or housing vouchers a PHA can manage or issue, lack of funding compared to the need constrains the ability of PHAs to assist low-income households. In 2020, Coloradans were on waitlists for Housing Choice Vouchers for an average of 17 months. Waitlists also exist for the other rental assistance programs.

Statewide Program Access 2015-19: Over the study period of this report, an average of 21.1% of renter households with incomes at or below 50% AMI (i.e., the population who is likely to be eligible for HUD rental assistance programs) were living in subsidized housing.