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May 11, 2017

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2017 Legislative Wrap-up: Health Care

by | May 11, 2017

Health

This year, CCLP’s Health Care program developed and supported successful efforts to address the shortcomings in client correspondence for Medicaid recipients. We mitigated punitive measures on low-income Coloradans in negotiations to establish an enterprise for the hospital provider fee. We also supported efforts to curb the rising cost of health care. On national issues, we took a leadership role in a coalition that communicated with Colorado’s Congressional delegation and urged Coloradans to make their concerns known about proposed sweeping policy changes that could compromise the access and affordability of health care for hundreds of thousands of Coloradans.

Here’s a brief recap of CCLP’s health care work during the 2017 legislative session:

Good news
Medicaid correspondence package — CCLP worked with its partners, including the Colorado Cross Disability Coalition, to pass three bills intended to address shortcomings in client correspondence and notifications when Medicaid health care and essential services are about to be changed or terminated. The bills were developed by an interim committee led by then Rep. Dianne Primavera because notices sent to Medicaid clients are often incorrect and incomprehensible. Such deficiencies violate basic due process requirements. House Bill 1126 strengthens the role of administrative law judges in safeguarding the rights of Medicaid clients by instructing the judges to automatically review the sufficiency of notices at the beginning of any appeal hearing. HB 1143 directs the state to audit communications with Medicaid clients for legal sufficiency, clarity and accuracy to prevent Medicaid notification issues from reoccurring. Finally, Senate Bill 121 makes notices more comprehensive and helpful by requiring plain-language statements, specific reasons for an adverse action and translations in a client’s preferred language. All three bills passed through the legislature with bipartisan support and, to date, two have been signed by Gov. John Hickenlooper.

Hospital provider fee enterprise — After three years of effort, legislators finally passed a bill authorizing the establishment of a hospital provider fee enterprise. SB 267 establishes an enterprise to collect and administer the hospital provider fee and provide other services to Colorado hospitals. It was essential that this bill pass, given that hospitals faced a reduction of $528 million in provider fee funding while the state faced the prospect of increasing reductions in available General Fund money because of the provider fee. That being said, SB 267 is by no means perfect. In addition to establishing an enterprise, the bill reduces the amount of revenue the state can raise to fund services by $200 million; requires the executive branch to work towards submitting a budget proposal for fiscal year 2018-19 that reduces state general fund expenditures by 2 percent across every department; and doubles Medicaid co-payments for pharmacy and out-patient hospital services. Ultimately, the bill will provide more funds for schools, transportation, and capital improvements and reduce personal property taxes on businesses. But, we are extremely disappointed that achieving that benefit could only be negotiated by imposing a cost on low-income Coloradans.

PACE ombudsman — Programs of All-inclusive Care for the Elderly (PACE) provide a range of services to people over the age of 55 who qualify for nursing-home level care but wish to retain their independence in the community. HB 1264 establishes a permanent PACE ombuds program. While the Disability Law Center and DRCOG took the lead, the bill is the culmination of work CCLP did in 2015 and 2016 on the conversion of InnovAge, Colorado’s largest PACE provider. As part of that conversion, the Colorado Attorney General ordered the establishment of an ombuds position to serve PACE programs for a three-year period. In 2016, the legislature codified that requirement and directed the Department of Human Services to make recommendations to make the program permanent. Those recommendations led to the passage of SB 264.

Codifying the Accountable Care Collaborative (ACC) program — In existence since 2011, the ACC program is Colorado’s mechanism for realizing delivery system and payment reform in Medicaid. While many states have adopted traditional Medicaid managed care, Colorado has maintained a managed fee for service program and implementation is moving slowly, based on the results of pilot programs, towards payment reform. The ACC has shown positive results both in improving care coordination, health outcomes and reducing costs. By codifying the program, HB 1353 ensures the stability of the ACC going forward.

Addressing the opioid crisis — Several bills this session targeted the growing epidemic of opioid overuse and addiction. SB 074 created a pilot program to increase access to treatment in certain areas of the state. SB 193 established a center at the University of Colorado for research into prevention, treatment and recovery support. HB 1351 appropriates funds to collect and analyze data to assess how to improve substance-use disorder treatment within the Medicaid program in Colorado. All three bills passed and are heading to the Governor’s desk. To cap off the session, Rep. Brittany Pettersen’s request for an interim committee on substance-use disorders in Colorado was approved.

Disappointments
Bills to reduce health care costs – Prompted by the extraordinarily high cost of insurance along Colorado’s I-70 corridor, Lt. Gov. Donna Lynne brought together a working group last fall to develop ideas to reduce the cost of health care. Unfortunately, all the bills proposed by the group were defeated — almost all of them in the Senate State Veterans and Military Affairs Committee (known under the dome as “the kill committee”). Cost containment strategies ranged from increasing transparency by requiring hospitals to submit audited financial statements and Medicare cost reports to the Department of Health Care Policy and Financing (HB 1236) to establishing a program for temporary relief from the high cost of health insurance for people just above eligibility for premium tax credits through Colorado’s health insurance exchange, Connect for Health Colorado (HB 1235). Among the others were: HB 1286, which would have required health plans contracted with the state to cover state employees to participate in additional markets to increase competition and choice; and HB 1318, which would have established an annual report on pharmaceutical cost data to better understand the underlying costs of prescription drugs. In every instance, industry interests coupled with reluctance to use government to reduce health costs resulted in failure of these bills.

Balance-billing bills — For the third year in a row, efforts to curb costs associated with free-standing emergency rooms failed (SB 64), as did yet another attempt to protect consumers from the practice of balance billing – charging consumers for the full cost of out-of-network services (SB-206).  These efforts were strongly opposed by the Colorado Hospital Association and the Colorado Medical Society.

Risk-pool reinsurance – SB 300 was a late effort to prepare Colorado for the potential availability of federal funds to establish a high-risk pool or reinsurance program. The bill would have given the Division of Insurance the authority to seek a waiver under Section 1332 of the Affordable Care Act. Such a waiver would create the opportunity for Colorado to establish a reinsurance program in order to reduce health insurance premiums in the individual and small-group market.  Unfortunately, while the bill was approved by both chambers and sent to the Governor, it was turned into a study to be completed by Oct. 1.

Challenges and opportunities ahead
The biggest unknown in health policy is what will happen in Congress with respect to the attempt to repeal and replace the Affordable Care Act. If approved by the U.S. Senate and President Trump in its current form, the American Health Care Act will dramatically change the health care landscape in Colorado — undoing more than a decade of work that has substantially reduced the number of people who are uninsured and ensured high quality care is available to every Coloradan.

We also don’t know, at this point, what Congress will do with the Children’s Health Insurance Program (or CHIP). The program’s funding expires in September 2017 and Colorado will run out of federal CHIP funds in February of 2018.

In addition to actions resulting from potential federal legislative changes, we note the following issues:

  • Establishment of the provider fee enterprise may enable policymakers to begin to plug gaps in coverage, for example with respect to substance-use disorder treatment. |
  • The Colorado Commission on Affordable Health Care will deliver its final report to the General Assembly this summer. While a proposed interim committee to examine its recommendations was rejected, we anticipate the report will generate discussion among policy makers about cost containment.
  • CCLP and its partners supported forming an interim committee to study the availability and accessibility of disability-support programs. While the request was denied by legislators, we are still exploring legislation that would achieve the results we would have through such an interim committee.

-By Elisabeth Arenales

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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.