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Dec 18, 2016

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Allison Neswood previously served as CCLP's Deputy Director of Strategic Priorities. She is an expert in public health insurance plans (Medicaid and CHP+), Aid to the Needy Disabled, immigrant access to services and health equity.

Recent articles

Proposed changes to Medicaid would hurt Coloradans

by | Dec 18, 2016

Health

Incoming White House and congressional leaders are reportedly planning to make deep cuts in federal funding for the Medicaid program which provides health care coverage for individuals and families with limited resources.

The first round of cuts would likely involve the repeal of federal funding for the Affordable Care Act’s (ACA) Medicaid expansion, which expanded Medicaid to cover low-income adults. The second round will likely limit the federal funding that supports traditional Medicaid – the portion of the Medicaid program that has served low-income children and people with disabilities since 1965.

Congressional leaders aim to have an ACA-repeal bill ready for the new President to sign immediately after he is inaugurated in January. Proposals to cut traditional Medicaid are expected to follow in the subsequent months. Those proposals, which include converting the federal Medicaid funding structure into a block grant or per capita cap, are expected to move quickly. That means it’s important for constituents to make their concerns known to their representatives right away. (Read the last paragraph of this posting to learn how to make your voice is heard by elected officials).

Background on Medicaid funding
Medicaid is a public health coverage program that is jointly funded by the states and the federal government. Medicaid spending is determined based on a fixed percentage of the overall costs of providing care to the eligible population. In Colorado, federal funding covers about half of the costs of providing care.

For the Medicaid-expansion population, federal funding covers 100 percent of the coverage costs until 2017. That federal share is set to decline by 5 percent by 2018 and by another 5 percent by 2020. However, the federal government will continue to cover 90 percent of the cost of the expansion after 2020.

Proposals to cut Medicaid
As mentioned earlier, the first congressional proposal would eliminate federal support for the Medicaid expansion under the ACA. In Colorado, the Medicaid expansion has provided coverage to more than 350,000 Coloradans. These are people who would not be able to afford health insurance in the private market. This coverage supports the health and financial security of workers and the stability of hospitals across the state. In addition, the expansion brought nearly $1.6 billion in federal funding into the state in its first two years. In economic terms, a Colorado Futures Center report found that the “Medicaid expansion … is already having and will continue to have a significant positive impact on the state’s economy” and has buoyed the state economy by expanding state GDP, growing employment and increasing annual household earnings.

The proposals to cut federal spending for traditional Medicaid are a bit more complex. Such proposals would end the flexible federal funding structure that allows federal Medicaid spending to respond to the changing costs of providing care — whether due to population growth, increases in health costs or emergencies or disasters. That structure would be replaced with a rigid block grant formula that would set base-year funding at current levels and grow funding annually based on the Consumer Price Index (or CPI). Meanwhile, the so-called “alternative” to block grants, the per capita cap proposals, would limit the amount of spending on each individual enrollee regardless of health status and allow the cap to grow based on CPI. Neither proposal takes into account that the rate of medical inflation is higher than what the CPI reflects. Both are equally bad in terms of undercutting the ability of the Medicaid program to provide health care to the population in need.

Block granting Medicaid will result in cuts because the formulas don’t reflect population growth. The proposal also ignores the increasing cost of providing medical care and doesn’t allow the federal Medicaid budget to expand when downturns in the economy or natural disasters create a surge in the number of people who are eligible for the program.

Per capita caps will allow federal funding to adjust with changes in the size of the eligible population. However, these caps will still result in significant cuts because they do not take into account the increasing costs of medical care or individual needs for services.

The 2016 block grant proposal from Rep. Tom Price, president-elect Trump’s nominee for Health and Human Services Secretary, would reduce the federal contribution to Medicaid by $1.5 trillion over ten years and shift that cost to the states or to low-income people. That is a $1.5 trillion cut for a program that already spends 18 percent less per Medicaid enrollee than is spent per enrollee in the private market, when you consider people with similar health status.

It’s not about flexibility
Block granting is not about flexibility. The Medicaid statute already has waiver provisions that give states a large amount of flexibility to innovate — provisions many states, including Colorado, have used.

More accurately, block granting is about reducing the federal contribution to Medicaid and shifting that financial responsibility to the states and/or to low-income people. Block grants — especially when coupled with the repeal of Medicaid expansion funding — will create enormous funding gaps that will put states in the position of substantially cutting benefits or substantially increasing state spending to maintain services.

In Colorado, block granting traditional Medicaid is expected to result in a significant reduction in federal Medicaid funding over 10 years. Medicaid provides prenatal care so that Colorado children are born healthy and ensures that people with disabilities and low-income seniors can access long-term care services. Over the past year, the Medicaid expansion provided care to more than 12,400 people with cancer, 30,200 people with diabetes and 103,000 people with mental health treatment needs. Cutting funding to the program affects our state, our rural communities, our hospitals, and our insurance rates as hospitals shift uncompensated care to the insured.

As I mentioned, the federal Medicaid laws allow states significant flexibility to constrain growth and design a program that suits the needs of their population. Colorado has taken advantage of that flexibility to serve more Coloradans and to spur health care innovation and improve the value of care. There is still work to do, but our current approach seeks to optimize savings by reducing actual health care costs rather than by reducing services or cutting eligibility.

Block grant proposals will put states in the uncomfortable position of either raising more money to fill in huge reductions in federal funding, or forcing them to make choices about reducing access to care. From a policy perspective, forcing states into this position lets the federal government off the hook under the guise of newfound “flexibility.”

Since we in Colorado already have that flexibility, let’s not be fooled by the terms of the proposed bargain from Congressional leaders and the White House. In short, it’s a terrible deal that would have long-term consequences for the health of too many people.

If you are concerned about how these proposed changes to Medicaid and the ACA would hurt Coloradans, please make sure your voice is heard by Gov. John Hickenlooper and Colorado’s Congressional delegation. Read this “call to action” for more details.

By Allison Neswood

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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.