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May 18, 2018

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2018 Legislative Wrap-Up: Health Care

by | May 18, 2018

Health, Legislative Updates

Health care is no less contentious in Colorado than in the rest of the United States, with rising costs, the Affordable Care Act (ACA) and Medicaid galvanizing and sometimes polarizing the legislature. With health being such a hot-button topic, results were mixed during this session, but there were some notable victories.

This year, CCLP supported efforts to make health care costs more transparent to both payers and consumers, opposed efforts to undermine Medicaid eligibility and services, worked on programs to make coverage more affordable in rural parts of the state, and promoted legislation to better address the need for treatment for substance use and mental health disorders.

Here’s a brief recap of CCLP’s health care work during the 2018 legislative session:

Price transparency

Even though policymakers on both sides of the aisle have called for greater accountability in health pricing, legislation could not overcome industry opposition. House Bill 1260, the Drug Pricing Transparency Act, got further through the process than prior efforts in 2017 and 2016, but was ultimately defeated in the Senate Committee on State, Veterans & Military Affairs. Led by consumer groups, including CCLP, this bill would have required that carriers report on drugs that are most expensive for Coloradans and that manufacturers give advance notice of large price increases in drugs and explain price increases when they exceed a certain threshold. The legislation also called for annual reporting by the Division of Insurance on the effect of pharmaceutical pricing on plans regulated by the Division of Insurance (DOI).

Another transparency bill, HB 1207, would have required hospitals to report expenditures related to the receipt of hospital provider fee funds, which are intended to compensate hospitals for Medicaid underpayments and uncompensated care. CCLP supports access to information about the use of these funds, which have been less successful than hoped in deterring hospitals from shifting costs to the private insurance market. This was the second year this kind of legislation failed.

Improved consumer notice regarding pricing faced similar obstacles. For the third year in a row, CCLP supported a bill to protect consumers from “surprise billing” by out-of-network providers. Too often, Coloradans who have had surgery or other services at in-network or emergency facilities find themselves on the hook for surprise bills from out-of-network providers. These bills typically far exceed in-network costs. Senate Bill 237 would have required health care facilities, providers and health insurers to provide disclosures to consumers about the potential costs of receiving non-emergency services from an out-of-network provider or emergency services at an out-of-network facility. Ultimately, SB 237 failed — leaving consumers without clear information and at risk of paying bills for which they aren’t liable.

On a brighter note, in the third year of such efforts, two of three free-standing Emergency Department (FSED) bills passed. CCLP supported all three bills. Signed into law by the governor, HB 1282 now requires every hospital associated facility to acquire its own federal billing number, so that payers can better assess individual facility charges. Another bill signed by the governor, SB 146, requires FSEDs to provide consumers with information regarding potential charges, the right to ask questions about care and cost, and the in- or out-of-network status of the treating facility. HB 1212, an effort to require hospitals and FSEDs to justify facility fee charges, failed. FSEDs, which often locate in affluent areas and charge exorbitant fees, are credited with raising the cost of insurance as well as saddling consumers with high out-of-pocket obligations.

Coverage and benefits under public programs

This session, CCLP pushed for improved access to services for disabled and low-income Coloradans. SB 214 proposed adding work requirements and a life-time limit on Medicaid by requiring the Colorado Department of Health Care Policy and Financing (HCPF) to pursue a federal waiver to Colorado’s Medicaid program.

CCLP worked with other members of the Protect Our Care coalition to rally a broad and powerful showing of opposition to SB 214. The bill died on a bipartisan vote in its first committee in the Senate. CCLP also led the successful effort to pass SB 174, expanding the list of qualified mental health professionals who can verify eligibility for the Aid to Needy Disabled (AND) program for people with mental disorders.

In addition, we spearheaded HB 1192, which would have funded a program to assist people in applying for federal Social Security disability benefits (SSI/SSDI). That bill carried a fiscal note legislators were unwilling to fund this year, but we will try again in 2019. We were able to persuade lawmakers to amend SB 136, which allows brokers to charge customers for assistance with purchasing health coverage. The amendment bars brokers from charging those who are eligible for Medicaid or CHP+.

Finally, SB 266 was drafted by the Colorado Department of Health Care Policy and Finance (HCPF) to grant HCPF additional authority to control costs. Though CCLP supports efficiency in the program, we are concerned that the bill may signal a shift toward traditional managed care, a system that is not typically oriented toward delivering quality care to a population with special needs. We were unable to make modifications to the bill.

Health care affordability 

Efforts to address soaring health insurance premium costs across the state — but particularly in rural areas — took several forms. HB 1392, which would have established a state reinsurance program, failed in Senate State Affairs despite a many-month stakeholder process and bipartisan support. That bill would have authorized the Division of Insurance to submit a waiver for a state reinsurance program that would have reduced premium costs in the individual market, up to 35 percent in the highest-cost areas in the west, 25 percent in the east and mountain corridor, and 20 percent elsewhere. While the plan would appear to have both increased affordability and made those high-cost markets more attractive to carriers, opposition from the insurance industry and some business groups proved fatal.

HB 1384, proposed that DOI and HCPF study the feasibility of alternative insurance products, including a public-private plan option and a product that utilizes the low cost infrastructure of Medicaid/CHP+, with the goal of expanding affordable options for high-cost communities in Colorado. Both HB 1392 and HB 1384 were voted down in the last week of session.

SB 132 purported to increase insurance options, by aiming to expand the pool of people eligible to purchase catastrophic plans. Under the ACA, only adults under 30 and people who qualified for a hardship exemption could purchase such plans, which provide minimal coverage. However, catastrophic plans leave many enrollees under-insured, and greater availability of such plans may destabilize the individual market and deter people from getting the subsidies available for more robust plans. While the bill passed, giving the state authority to apply for a waiver of the ACA provisions, we were able to secure amendments that require an analysis of the potential risks and benefits of offering catastrophic plans and a three-year review prior to reauthorization of the program.

Substance use disorders 

A slate of bills addressing substance-use disorders and supported by CCLP had significant success this year.

The Opioid and Other Substance Use Disorders Interim Study Committee led by Rep. Brittany Pettersen, D-Lakewood, yielded six bipartisan bills, with one highlight being HB1136, which will add residential treatment and inpatient medical detox benefits to the Medicaid program via a Medicaid waiver. The waiver should also provide an opportunity to streamline and coordinate substance use disorder services, addressing fragmentation in the current delivery system.

SB 22 limits opioid prescribing practices, to ensure that fewer patients receive excess medication which increase the risk of misuse, while protecting access for those with chronic pain or disability. SB 24 provides loan forgiveness and funding for behavioral health providers, and HB 1003 establishes a legislative substance use disorder committee, allows school-based health centers to apply for grants to help with prevention and intervention services and increases SBIRT (screening, brief intervention and referral to treatment) services. HB 1007 requires coverage by commercial plans and Medicaid for certain medication-assisted treatments (MAT) without prior authorization or other obstacles to initiating care.

Of the six, only SB 40, which would have piloted a safe-injection site in Denver, failed.

– 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.