The West Virginia Senate passed a bill on Tuesday that seeks to protect West Virginians with preexisting health conditions, in the event the federal law that currently provides those protections is repealed.
Senate Bill 284 is on its way to the state’s House of Delegates after passing the Senate 20 to 14 Tuesday afternoon, along party lines. The legislation would only go into effect if the federal Affordable Care Act, also known as “Obamacare,” was repealed.
The bill’s lead sponsor is Sen. President Mitch Carmichael, R-Jackson, and it has support from West Virginia’s Attorney General Patrick Morrisey. Morrisey joined a lawsuit with other Republican attorneys general in 2018 to repeal the ACA’s individual mandate to purchase health insurance.
The bill would require the state’s insurance commissioner, currently James Dodrill, to issue a public notice when the federal government has determined “all or a significant portion” of the ACA in unconstitutional.
Dodrill and other West Virginia health officials will then work on creating a reinsurance program, to support health insurance companies caring for individuals who, due to a serious health condition, have high health care costs.
The bill doesn’t specify a method for funding that reinsurance program, but it allows the state to study the implementation of a high-risk pool.
West Virginia was one of several states operating a high-risk pool before the ACA began. Some experts have said these pools were more expensive to the people who benefited from them than they were helpful.
Morrisey has said in numerous interviews and press conferences he joined the ACA lawsuit in 2018 due to “skyrocketing” premiums and concerns over constitutional rights.
Several groups advocating for affordable health care have said a repeal of the ACA would affect people with preexisting conditions, if there’s not a backup plan in place.
One of the bill’s opponents — Sen. Richard Lindsay, D-Kanawha — said in a Feb. 13 interview with West Virginia Public Broadcasting the reinsurance program, depending on how its funded, could lead to higher premiums across the state.
Lindsay spoke against the bill on Tuesday in his remarks to the full Senate, saying the Morrisey-supported bill was unfair to people with preexisting conditions who benefit from the ACA.
“It would be analogous to having a three floor house with six bedrooms and four bathrooms,” Lindsay said, “and an individual burning it down to the ground, and forcing you to buy a house from him that’s half the size with very little space.”
He also opposed the bill because the Senate didn’t take up a Democrat-led bill, a shorter proposal which was introduced to protect people with preexisting conditions. That bill also didn’t address funding mechanisms.
A federal appeals court in New Orleans in December decided the individual coverage mandate in the ACA was unconstitutional. The federal court returned the case to a lower court in Texas who ruled the same thing months earlier, to determine how much of the ACA contradicts the U.S. Constitution, and what — in the court’s opinion — should be repealed.
If the law is repealed, West Virginians also risk losing ACA-provided subsidies to pay for personal insurance.
A report from West Virginia MetroNews in October said 22,600 West Virginians were enrolled in the state’s health insurance exchange last year. Eighty-eight percent of this population received subsidies in some amount, to pay for these plans.
Senate Bill 284’s provisions for people with preexisting conditions only applies to West Virginians under the state’s jurisdiction, who purchase their insurance independently. The bill doesn’t do anything for West Virginians covered by Medicare, Medicaid, or private employment-based health benefits for companies which self insure.
The legislation has been assigned to the House Health and Human Resources Committee for consideration.
If policymakers use market-based approaches to solve healthcare access problems, they need a better understanding of how rural markets work, says one researcher.
A lack of competition among health insurers in rural areas has reduced the ability of market-based approaches to increase insurance enrollment, a new study says.
The Affordable Care Act of 2010 sought to improve the health-insurance access in part through fostering more competition among insurers. But rural markets have less competition than metropolitan ones, so the impact of market-focused strategies is diminished, according to a study by the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis.
The study looked at insurer participation data across three market-based health insurance programs — the Federal Employees Health Benefits Program (FEHBP), Medicare Advantage (MA) and Health Insurance Marketplaces (HIMs – which were created under the Affordable Care Act). Researchers aimed to see whether the competition within an insurance market affected an individual’s decision to purchase health insurance.
That information is key in determining whether market-based health-insurance helps increase enrollment rates in rural areas where population is less dense.
The study found that, in areas that had been dominated by a smaller number of insurers in the past, the Affordable Care Act’s health-insurance marketplaces for individual policies had lower enrollment.
“This finding suggests that an underlying level of competition, based upon historic and/or institutional factors, plays a role in [the Affordable Care Act health-insurance marketplace’s] success or lack thereof in rural places,” the study said.
The study also indicates that a lack of population density doesn’t lower health-insurance enrollment. Rather, the region’s previous lack of competition predicted the lower enrollment rates.
The study used data from the three health insurance programs, as well as the “Herfindahl Index,” which measures market concentration.
Data showed that insurer participation began to decrease in 2017, across the country, but most especially in rural counties and in states that did not expand Medicaid.
Focusing on counties with population densities below 100 people per square mile, the study found that counties that continued to attract insurers tended to have lower prior-year Herfindahl indexes, meaning the counties previously had market competition.
“Over the first four years of [health-insurance marketplace] operation, 2014-17, there was significant entry and exit of insurers in both urban and rural counties,” the study found. “In 2017, data began to show signs of weakening insurer participation, especially in rural counties and in states that did not implement Medicaid expansion.”
The study concluded that a complex set of factors, not just population density, made rural areas less competitive.
“Years of evidence across three market-based health insurance programs clearly indicate that rural places are less competitive,” the study found. “Our findings suggest that while this is due in part to the limitations of small populations, low population density, and fewer available providers, other factors are also at work.”
Those other factors can include things like “the presence and type of hospital systems, the policy environment at the state level, the entrenchment of certain insurers who were early entrants to the private market, the payer mix and even the specific geography in terms of terrain and infrastructure.”
Abby Barker, with RUPRI, said in an email to the Daily Yonder that the study points to the need for a re-evaluation of how rural areas are different than urban areas.
“I think you could say that population density, and some of those other population-related measures… are expected to be significant. But what we added is this measure of competition that shows that another explanatory factor is how concentrated the market is and has been over time. The methods don’t really identify which is MORE important, but the contribution of this work is to say that prior market concentration matters. In my view, it suggests that policies that rely on competition to achieve certain access/affordability goals, really have to be intentional about overcoming this sort of inertia that tends to exist. Once certain insurance issuers are established in a particular geographic region, it’s a little harder for new ones to come in.”
Policies should address the specific needs of rural areas in the future, she said.
“This brief didn’t really examine the urban county data, but I think implicitly our message is that rural places DO have the potential to be different in terms of how much we can rely upon the market model to work well, at least in certain rural places, at least without recognition that rural places may require something explicit in a market-based policy to mitigate these types of issues,” she said.
This article was originally published by the Daily Yonder.
Enrollment plans in West Virginia through the federal online health insurance marketplace has declined again this year.
Citing the Centers for Medicare and Medicaid Services, the Charleston Gazette-Mail reports about 22,600 West Virginia residents signed up for a 2019 plan on healthcare.gov. Individuals can buy Affordable Care Act-compliant health insurance plans through the website.
Last year, around 27,400 West Virginians signed up for plans. In 2017, the enrollment number for the state was around 34,040.
West Virginians for Affordable Health Care Executive Director Chantal Fields says one reason for the decline may be residents moving from ACA plans onto Medicaid and Medicare rolls.
Beginning with 2019 plans, individuals will no longer pay a penalty on their income taxes if they don’t have health insurance.
A new study from Indiana University has found that the Affordable Care Act led to an increase in early-stage cancer diagnosis in Medicaid expansion states like West Virginia.
The research suggests that public health insurance may increase cancer detection. Early cancer detection is linked to better outcomes for patients and fewer deaths. West Virginia has one of the highest rates of cancer in the nation.
The research found that Medicaid expansion increased early cancer detection rates by 6.4 percent from pre-ACA levels. There was no detectable impact on late stage cancer diagnosis rates.
Researchers concluded that expanding access to health insurance and health care has a measurable impact on diagnosis and treatment.
The study was published this month in the American Journal of Public Health.
Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Marshall Health, Charleston Area Medical Center and WVU Medicine.
Data released Tuesday by the United States Census Bureau shows the Affordable Care Act continues to reduce the number of West Virginians without health insurance.
In 2016, 96,000 West Virginians lacked health insurance coverage – that’s down 12,000 from the previous year, according to a news release from the West Virginia Center on Budget and Policy – which studied the U.S. Census Bureau’s data.
Nearly 95 percent of West Virginians had health insurance last year.
Between 2013 and 2016, West Virginians without health insurance declined by 9 percent. West Virginia has had the fifth largest decrease in its uninsured rate among all 50 states under the ACA.
Interim Executive Director for the West Virginia Center on Budget and Policy Sean O’Leary says the Affordable Care Act has been vital to the overall health of the state. Particularly, he says, it’s aided with substance abuse issues and developing treatment for opioid addiction.
It’s hard to find a spot on the map where the proposed repeal of the Affordable Care Act would have a bigger effect than in the Ohio Valley. By one measure, for example, the proposal could mean West Virginia’s rate of people who lack health insurance would climb by nearly 300 percent — the biggest such change in the country. The projected declines in Kentucky and Ohio are also more than twice the national average. This is largely due to proposed changes in Medicaid.
As Congress debated Republican health measures that would roll back the ACA’s expansion of Medicaid, the full extent of Medicaid’s role in Kentucky, Ohio, and West Virginia gained more public attention. Rural hospitals, people living with disabilities, displaced coal miners, addiction treatment services, care for the elderly — all could be affected by cuts to Medicaid.
That rising awareness has focused public attention, sparked protest, and put some regional lawmakers on the spot.
As the ramifications of proposed changes to the ACA became clear, more health care providers began to speak up about the widespread but less obvious ways that Medicaid supports their work.
Hospital officials say Medicaid has been crucial in keeping rural hospitals open. The Kentucky Hospital Association estimates that rural hospitals and health centers in the state receive about 70 percent of their revenue from Medicare and Medicaid.
Credit Mary Meehan / Ohio Valley ReSource
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Ohio Valley ReSource
Teresa Fleming is the financial officer for one of those rural health centers, Mountain Comprehensive Care, which serves five eastern Kentucky counties. Fleming said the expansion of Medicaid came just as many coal miners in the region were losing jobs and health coverage.
“The Affordable Care Act came at the right time and basically correlated with the mine layoffs,” she said. “So that gave our patients safety or at least some security that they would have some kind of coverage so they could go see their providers.”
Services supported by Medicaid also allow people with disabilities to live in their communities and outside of institutions. According to the Kaiser Family Foundation nearly 760,000 people with disabilities in Kentucky, Ohio, and West Virginia depend on Medicaid.
Jeff Edwards, executive director of Kentucky Prevention and Advocacy, said those services allow people with disabilities to lead fuller lives and contribute to their communities.
“When we hear they are going to dismantle Medicaid we are thinking about adults, people who need some help in the morning to get dressed and get in a wheelchair but then go on to work a 40-hour-a-week job,” he said.
If those services are cut, he said, “We will start filling institutions back up.”
The Addiction Factor
The ACA allowed more people suffering with addiction to get more resources, according to treatment specialists throughout the region.
Looking just at numbers from the Medicaid expansion through the ACA, researchers at Harvard and New York University estimate nearly 215,000 additional people were able to seek addiction and mental health treatment.
In Portsmouth, Ohio, a city hit hard by the addiction crisis, the health department was able to connect more people to treatment thanks to the coverage gains.
Credit Aaron Payne / Ohio Valley ReSource
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Ohio Valley ReSource
Portsmouth, Ohio, public health nurse Lisa Roberts saw what happens when addiction treatment abruptly ends. “It could just be catastrophic.”
The progress they’ve made could be lost under the proposed repeal plans because Scioto County, where Portsmouth is located, also struggles with unemployment.
“So many of our people depend on types of insurances that would go away,” Lisa Roberts, a public health nurse with the department said. “We just have a lot of people here who don’t have access to good, regular, employee-covered health insurance.”
This resonates with Ohio Valley politicians considered to be key votes in the repeal effort.
Republican Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia both cited the potential loss of coverage and funding for addiction treatment as reasons they would oppose the current Senate plan.
Credit Rebecca Kiger / For the Ohio Valley ReSource
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For the Ohio Valley ReSource
Senate leaders attempted to win back their support with the promise of $45 billion in addiction treatment funding spread out over about a decade, up from $2 billion in an earlier version of the bill.
But treatment specialists and state leaders say that’s far from enough to make a difference.
Ohio’s Republican Gov. John Kasich said on ABC’s “This Week” that the funding was “like spitting in the ocean. It’s just not enough.”
The left-leaning Center for American Progress estimates that Kentucky, Ohio, and West Virginia would get a $443 million share of the funds per year over that time period. But the CAP analysis estimated the full cost of treatment in Ohio alone would be over $2 billion by 2026.
It’s difficult to predict these numbers with complete accuracy due to the changing nature of the opioid epidemic and state investments in more treatment efforts. But numbers like these are enough to give Senators Portman and Capito pause when considering a repeal effort.
Public Protests
Sen. Capito and other regional lawmakers have also been the focus of newly energized activists who have organized numerous sit-ins, marches, and other events that saw people taking to the streets, even in some places that are deep-red in their politics.
Credit Mary Meehan / For the Ohio Valley ReSource
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For the Ohio Valley ReSource
The demonstrations frequently included people with disabilities or health problems advocating for themselves — people in wheelchairs or those with chronic conditions who couldn’t stand for long but who turned out anyway. Many independent, grassroots groups coordinated via social media to create “pop up“ protests at every turn of the legislative process.
Demonstrators were also fueled by fresh reminders from emerging science showing just how important health care access is in the area.
A study published in the Journal of the American Medical Association’s publication JAMA Internal Medicine made headlines during the health debate for its conclusions that in parts of the Ohio Valley people can now expect to live shorter lives than their parents did.
The study found that Kentucky, Ohio, and West Virginia include 27 of the 50 counties with the country’s worst trends in life spans. Of the 10 counties in the U.S. with the worst declines in life expectancy, eight are in Kentucky.
It’s difficult to say what effect the activism has had on decision makers, but the correlations provide some indication. After activists staged sit-ins in her offices, for example, Sen. Capito issued a statement voicing her concerns with the Senate’s repeal-and-replace bill. “I did not come to Washington to hurt people,” she wrote.
Conflicting Claims
The protesters and Republican supporters of the bill had starkly conflicting messages about Medicaid’s future. Protesters often cited the Congressional Budget Office estimate that 22 million people could become uninsured under the Republican plan, due in part to Medicaid changes.
Kentucky Republican Sen. Mitch McConnell, the Senate’s Majority Leader, had a very different message when responding to a protest at a recent event in Paducah, Kentucky.
“Nothing that we’ve advocated so far would cause anybody currently on Medicaid to be taken off of Medicaid,” he said.
Credit Nicole Erwin / Ohio Valley ReSource
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Ohio Valley ReSource
Sen. Mitch McConnell faces protesters at events around Kentucky.
Simon Haeder is an assistant professor at the John D. Rockefeller IV School of Policy and Politics at West Virginia University, where he focuses on health care policy. Haeder said McConnell parsed his words carefully to make that argument, emphasizing people who “choose” to leave. That would include people who signed up for health insurance only because the original ACA mandated that coverage.
But Haeder points out that many who qualified for Medicaid under the ACA’s expansion would likely make that “choice” to leave Medicaid only because they would find they could not re-enroll after revisions to guidelines for Medicaid qualification. Many families are eligible for Medicaid under expanded ACA income guidelines gave that option to more working class people. If those expanded income guidelines are rolled back, Haeder explained, people wouldn’t technically get “kicked off” of Medicaid but they would no longer be eligible to continue their Medicaid enrollment because their income was too high.
“The semantics are there to work with, I guess,” Haeder said of McConnell’s claim, “but the reality is very, very different.”
Others, he said, could be pushed off Medicaid and not be able to afford private insurance premiums. It’s also hard to predict an ever-shifting population of those who are eligible for Medicaid.
Not Over
Haeder said the ongoing debate helped educate people about the scope of Medicaid. A wide variety of groups from the American Medical Association and AARP to grassroots activists voiced their concerns. Haeder said that despite the apparent demise of the latest Senate bill, that conversation will continue, as will the legislative efforts to change the health care system.
“A lot of the stuff that is being discussed like the cuts to Medicaid can come back really, really quickly,” he said. “For example, in the budget negotiations coming up. It is not over by any stretch of the imagination.”
