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Jul 25, 2019

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The Long, Winding Road to Implementing Health and Economic Justice Legislation

by | Jul 25, 2019

Family Economic Security, Health, Legislative Updates

Legislators passed, and the governor signed, a number of good bills into law during the 2019 Colorado legislative session – including 13 that Colorado Center on Law and Policy led. If implemented correctly, we believe these bills will improve the health and well-being of many Coloradans and advance the goal of equity in the state.

Once a bill is signed, the questions we ask to guide our work include: How do we ensure the implementation reflects the intent of the bill? Who is charged with enforcing the new rules? And who will inform those affected by the law? Getting to the heart of these questions will determine the success of these policies as they move forward.

The volume of successful bills from the last legislative session has kept CCLP staff busy with implementation efforts well underway. Our implementation efforts have included weighing in on the structure of waiver applications to federal agencies and addressing rulemaking by state agencies, including the Division of Insurance (DOI), the Department of Health Care Policy and Financing (HCPF), the Colorado Department of Human Services (CDHS), and the Colorado Department of Labor and Employment (CDLE).

Among other things, we’re participating in agency-led stakeholder committees tasked with developing new state government programs. Grounding our work in research is a critical part of those efforts, and equally important is continuing to engage members of the community – particularly those who may benefit directly from the new laws – through townhall meetings, printed collateral, media, etc.

Here’s a sampling of what’s ahead with our implementation efforts in the months and years to come:

HEALTH
Health Care Public Option (House Bill 1004) – Passage of the public option bill kicked off an intensive five-month plan by HCPF and the DOI to develop an affordable health coverage option that uses state health infrastructure. A series of public meetings has begun, with the state agencies dedicating July and August to hearing about the wishes and needs of community members outside the Denver metro area. Consumer groups are working closely together so that our recommendations represent Coloradans’ diverse interests and address the needs of uninsured and underinsured households. In 2020, we can expect more legislation, a possible federal waiver application, or rulemaking – and possibly all three.

State Reinsurance Program (HB 1168) – The state reinsurance program is making rapid progress, with public meetings held and a waiver already under consideration by the U.S. Department of Health and Human Services. Provisional 2020 rates show the program has already reduced individual plan rates for next year by an average of more than 18 percent. CCLP has submitted comments in support of the waiver and will work with other advocates and our state exchange, Connect for Health Colorado, to ensure that its approval translates into thousands of uninsured and underinsured Coloradans having more access to affordable health care.

Primary Care Investment (HB 1233) – Compared to many other countries, the United States spends more overall on health care (particularly specialty care) but does a poorer job coordinating care and preventing disease. HB 1233 seeks to shift that balance by creating a mechanism to increase health care dollars spent on primary care. CCLP is represented on a statewide, DOI-led collaborative that will work over the next several months to advise on standards and targets for improving investment in primary care services.

State Behavioral Health Parity (HB 1269) – This legislation aims to reduce barriers to accessing behavioral health services in Medicaid, as well as in commercial coverage regulated by the DOI. The DOI has moved swiftly on new regulations that require carriers to demonstrate that their plans provide parity between behavioral health and medical benefits, and more are in process. The state’s Medicaid program, Health First Colorado, has yet to introduce rules to implement the bill, and CCLP and consumer groups will continue to urge them to act quickly. Our priorities include clear, enforceable regulations requiring that the entities delivering behavioral health services have adequate networks and ensure prompt access to follow-up treatment, that people with co-occurring diagnosis like developmental disabilities or substance use disorder are not shut out of coverage and that criteria used to approve or deny care are appropriate and consistent statewide.

Hospital Community Benefit Accountability Bill (HB 1320) – This legislation requires nonprofit hospitals to report the community benefit they provide in exchange for substantial tax breaks and ties those efforts to health disparities identified in federally required health needs assessments conducted every three years. CCLP is engaged with HCPF to urge a user-friendly electronic reporting format that will allow the public to compare their local hospitals’ efforts to identify and address community priorities with others in the state.

HOUSING
Eviction Legal Defense Fund (Senate Bill 180) – As the lead organization behind SB 180, which created a $750,000 fund to provide legal services for Coloradans facing eviction, we provided recommendations to State Court Administrators Office about what criteria should be included on grant applications. This is not a competitive process, so multiple entities could be funded to provide legal help beginning Oct. 1, 2019.

Extend Notice Prior to Eviction (HB 1118) – This bill gives families the chance to avoid eviction or find other housing by extending the eviction notification period from three to 10 days for non-payment of rent. Since the legislation became effective immediately after the governor signed it, CCLP staff talked with the State Court Administrator’s Office to ensure that court staff was notified and online official forms regarding eviction notification were updated.

Mobile Home Park Oversight Act (HB 1309) – This legislation was designed to level the playing field for homeowners residing on rented lots. The act contained many elements but adding an administrative remedy to address complaints of violation of the Mobile Home Park Act will require the most work. The Department of Local Affairs will need to add additional staff to provide an administrative process by May, 2020 so that mobile home park residents will not need to hire an attorney to register a complaint.

Expand Supply of Affordable Housing (HB 1322) – With the passage of the largest-ever influx of funding for affordable housing — $30 million a year for three years from the state’s unclaimed property fund – communities have a chance to develop their own proposals for next year when funds become available. CCLP will join its partners in the Colorado Coalition for the Homeless’ State Disparities Grant by visiting 10 communities in the state over the next year to call out the funding opportunity while emphasizing the role of housing as a social determinant of health.

INCOME
Ban the Box (HB 1035) – Members of CCLP staff will meet with the CDLE staff charged with implementing the new law, which prohibits most employers from asking about criminal history on an initial employment application. Discussions will focus on how to inform the public and employers about the change and how it will be enforced. Though the law takes effect in September, businesses with fewer than 11 employees have until September, 2021 to be in compliance.

Emergency Employment Support Services (HB 1107) – This bill appropriates $750,000 to establish a three-year pilot program to provide small-dollar emergency transactions for Coloradans trying to get into the workforce or improve their skills to get a better-paying job. CCLP staff has met with those at CDLE charged with implementation to discuss the bill and concerns about implementation. We’ve made suggestions for what criteria should be for the entity administrating the fund. We also volunteered to review the bids. Since the funding is very modest, CCLP will develop a resource guide to other support service funds and look for opportunities to increase available funding.

Wage Garnishment Reform (HB 1189) – This bill will reform the state’s wage-garnishment laws by requiring clearer and more-timely notice of garnishment. It also will reduce the amount subject to garnishment to help people meet household needs while paying their debts. The implementation timeline was extended on this legislation to allow notice to creditors of new notification requirements. The bill applies to writs of garnishment issued on or after Oct. 1, 2020 Wage garnishment notices and legal forms will need to be revised and court staff notified.

SSI/SSDI Application Assistance (HB 1223) – Navigating the complex disability application for Social Security is a challenge for any applicant. For applicants living on the minimal state dollars available through the Aid to the Needy Disabled program – many of whom lack a stable address or have mental health conditions – the process is even more daunting. HB 1223 funds counties to provide application assistance and also requires stakeholder engagement in upcoming rulemaking. CCLP has been meeting with partner organizations to develop priorities and will be engaged in rulemaking this fall regarding how funds are distributed, how counties can qualify for them, and how the effectiveness of the program will be measured.

— By Bethany Pray and Chaer Robert

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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.