Georgians for a Healthy Future is a proud partner in the Specialty Tiers Coalition of Georgia, a group of consumer and patient advocates committed to ensuring affordable access to medications for patients with rare, chronic conditions. Earlier this month, the coalition hosted an educational forum at Emory University in Atlanta to raise awareness among policymakers and consumers about the growing trend of specialty tiers and the related risks to patients and consumers.

According to RheumatoidArthritis.org, specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hemophilia, and HIV/AIDS (remember the odds of contracting hiv). Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary (Tier One: generic drugs; a typical co-pay is around $10; Tier Two: preferred brand name drugs; a typical co-pay is around $30; Tier Three: non-preferred brand drugs; a typical co-pay is around $50) These drugs can also have a second effect on you, in this center people get treated when they become addicted to any drugs and substances.
. Specialty tiers, also known as Tier IV, V, or VI, add an additional structure for specialty medications — cost sharing known as “co-insurance” — where the patient pays 20-35% of the cost of the medication, rather than a fixed, predictable co-payment.  Unfortunately, there is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers.

The trend towards specialty tiers shifts costs to patients and places needed treatment out of reach for too many patients who are paying health insurance premiums to get the medical care they need, some need this special serums for your eyes and they are not receiving it.  Specialty tiers can result in drug costs well into the thousands of dollars per month for patients, increasing the likelihood that patients will go without needed treatment. In fact, a recent study found that one in four patients with an out-of-pocket prescription cost of $500 or more failed to fill their prescriptions. This indicates patients with insurance are having to choose between needed medications and everyday living expenses.

The Specialty Tiers Coalition will be active in the upcoming 2013 Legislative Session to grow awareness about this issue, and advocate for patient protections. Georgians for a Healthy Future and the coalition are currently serving as a community partner to the Health Legislation & Advocacy course at Georgia State University’s College of Law. Through this partnership, law students are providing research assistance and helping craft potential legislation to ensure adequate patient protections.

To read coverage of the October 10^th forum at Emory University, click here and here. To download a fact sheet on this issue from a coalition leader, Advocates for Responsible Care, click here.

Earlier this year, Governor Deal signed into law House Bill 1166 to restore child-only health insurance plans to the Georgia marketplace. The legislation was sponsored by Representative Atwood and supported by a broad coalition of consumer health advocates, health care industry stakeholders, and legislators, including Georgians for a Healthy Future. The law goes into effect on January 1, 2013, and will make standalone insurance policies for children available through an open enrollment period in January or in the event of a qualifying event throughout the year. The Georgia Department of Insurance is currently preparing the draft regulation, after which there will be a public comment period with the final regulation expected in December.

Several states around the country have taken similar action to make these plans available for children, and earlier this month the Commonwealth Fund issued a report examining legislative and regulatory efforts around the country during 2010 and 2011 and found that, in states that had taken action during those years, child-only coverage is now available in nearly all of those states. Since Georgia’s legislation was passed in 2012 and has not yet gone into effect it was not included in the analysis; however, the authors interviewed officials and advocates in Georgia and noted that legislation had been signed into law in 2012. Kaiser Health News also reported on the story last week. That article is available here. The study is available here.

Health exchanges are a central feature of the Affordable Care Act and are intended to provide meaningful and affordable health insurance options for individuals and families who don’t have access to health insurance at work. The exchange, or marketplace, will be a place where consumers can shop for private health insurance plans utilizing decision tools and accessing tax credits to make the plans affordable. By 2014, these marketplaces will be up and running in every state, with some states operating their own exchange marketplaces, some states partnering with the U.S. Department of Health and Human Services on a “state partnership exchange,” and some states deferring to a federally facilitated exchange.

States planning to move forward with their own state-based exchanges must submit a blueprint by November 16^th of this year.  Georgia is not expected to be ready for a state-based exchange, as reported in the Atlanta Journal Constitution last week, and thus a default to a federally facilitated exchange is likely in Georgia.

Ensuring that a health insurance exchange works for Georgia consumers is a key priority for Georgians for a Healthy Future, whether it is a state-based exchange, partnership exchange, or federally facilitated exchange. Regardless of who is administering the exchange on the back end, we must make sure it works for consumers on the front end. To that end, Georgians for a Healthy Future remains engaged in this important issue on behalf of health care consumers. Our Executive Director served on the Governor’s Health Insurance Advisory Committee in 2011, which studied options for Georgia, and submitted a minority report advocating for Georgia to move forward with planning for a state-based exchange despite the full committee’s recommendations against doing so; Georgians for a Healthy Future released a well-received policy brief in August 2011 making policy recommendations for a Georgia exchange; and our staff and coalition partners have been active in discussions with federal officials, along with consumer health advocates from around the country, about how to make sure federally facilitated exchanges are responsive to the needs of consumers within the states.

More information about the exchange blueprint submission process is available here; a summary of Georgia’s status on exchange planning is available here; and all archived materials from Governor Deal’s health insurance exchange advisory committee are available here.

Today, Georgians for a Healthy Future’s Executive Director Cindy Zeldin presented to the annual Georgia Women’s Assembly, organized by Georgia Women for a Change, on the Medicaid expansion and why it matters for women. We know that covering Georgia’s uninsured by implementing the Medicaid expansion will improve access to care, provide resources for the state’s health care delivery system, and bolster Georgia’s economy. But what about women in particular? Medicaid today provides a lifeline for many women, serving as a source of coverage for low and moderate-income pregnant women, low-income mothers, and low-income women diagnosed with breast or cervical cancer. Yet too many women are left out. Expanding Medicaid will extend that lifeline to more low-income moms and low-income women without children who aren’t eligible for Medicaid today.  More than two-thirds of uninsured women report difficulty accessing care, which tells us that too many women who want and need an entry point to the health care system to meet basic medical needs cannot get it today. The Medicaid expansion will help open that door. Another reason to Cover Georgia!

To download Cindy Zeldin’s power point presentation from the Georgia Women’s Assembly, click here.

More than 26,000 Americans die every year because they lack health insurance. Right here in Georgia, an estimated 1,000+ people died in 2010 because they didn’t have health insurance, among the most in the nation.  People who are uninsured are less likely to have a usual source of care, often go without screenings and preventive care, and delay or forgo needed care. This tragic reality has persisted for too long. Please join our friends at HealthSTAT in a candlelight vigil on Wednesday, October 24th at 7pm on the steps of the Georgia state capitol in memory of those who have lost their lives because they could not afford or did not have access to health insurance. Then, let’s redirect our energy towards covering all Georgians.

Georgia policymakers are currently weighing the opportunity to cover an estimated 650,000 uninsured Georgians through an expansion of the Medicaid program. Under the Affordable Care Act, states can create a new category of eligibility for Medicaid to cover low-income individuals and families, financed almost entirely with federal dollars. Implementing this expansion is the only viable way to cover Georgia’s low-income uninsured, and it will pump resources into our state’s health care delivery system. We can’t miss this opportunity to improve access to health care and to strengthen Georgia’s health care economy, but we need your voice to make it happen.

Health care consumer and patient advocacy groups, providers, stakeholders, and community groups are coming together under the Cover Georgia umbrella to show support for expanding Medicaid, and we invite you to join us. If you are interested in getting involved in this discussion, please contact Amanda Ptashkin.

In November, the Cover Georgia campaign will unveil a website full of resources to help you better understand and advocate for the Medicaid expansion with policymakers and in your community. In the meantime, please visit Families USA’s Medicaid Expansion Center, with links to studies and reports about the value of Medicaid, and the Center on Budget and Policy Priorities’ Tool Kit for State Advocates on the Medicaid expansion.

#CoverGeorgia

Gaining health care coverage through Medicaid improves access to care, reduces financial strain, and saves lives. Those are some of the takeaways from an engaging and enlightening forum hosted this morning by the Georgia Budget and Policy Institute. The featured speakers, Dr. Heidi Allen and Dr. Benjamin Sommers, presented research findings on the impact of gaining Medicaid coverage on health status and participated in a panel discussion moderated by GBPI’s Tim Sweeney and Georgians for a Healthy Future’s Cindy Zeldin about the implications for Georgia as our state’s policymakers weigh the costs and benefits of covering the uninsured in Georgia through an expansion of Medicaid. The audience was live tweeting the event under #covergeorgia, allowing those who missed to hear what the audience was saying as it was happening. You can read their tweets here. Georgia Health News also reported on the event (story here). To get involved with Cover Georgia, the emerging educational and advocacy effort to make the case for expanding Medicaid to cover Georgia’s uninsured, please e-mail Georgians for a Healthy Future’s Outreach & Advocacy Director, Amanda Ptashkin.

Here are some photos from today’s event.

Georgia consumers purchasing health insurance deserve the peace of mind that comes from knowing that they are purchasing a quality plan that meets basic standards and that will provide adequate protection in the event they get sick. That is why Georgians for a Healthy Future is monitoring the essential health benefits selection process. As part of the Affordable Care Act (ACA), beginning in 2014 all health insurance plans sold in the private individual and small group markets must include a minimum package of benefits to ensure that all consumers purchasing health insurance have access to comprehensive health care services.

In a process outlined late last year by the U.S. Department of Health and Human Services, states were instructed to choose a benchmark plan and supplement it to fill any gaps (the essential health benefits package must, under federal law, include items and services within ten broad categories, described here). Georgia chose the default option, the largest small group plan sold within the state, as our state’s benchmark plan. According to the Georgia Department of Insurance, the U.S. Department of Health and Human Services (HHS) will review and supplement the plan. You can read more about this issue and Georgia’s decision to default to federal officials on the decision in Georgia Health News here.

Later this fall, HHS is expected to issue a notice of proposed rule-making listing each state’s minimum essential health benefits package. The National Academy for State Health Policy is also tracking all states’ progress on essential health benefits. You can view their latest chart here.

This commentary originally appeared in the Atlanta Journal-Constitution on September 6th, 2012.

By Cindy Zeldin

Nearly 2 million Georgians are uninsured; that number is among the highest in the nation.

Georgia policymakers have long recognized this problem as a tragic reality for the one in five Georgians who struggle to access medical care when they need it, as a strain on our state’s health care delivery system, and as a weight on Georgia’s economy.

Until now, however, they haven’t had the tools and resources to comprehensively address it.

What has changed?

The Affordable Care Act  put in place a basic framework to ensure that all Americans have a pathway to affordable health care coverage. This framework has three key components. First, those of us who get health insurance at work as an employee benefit will continue to do so.Second, new health insurance marketplaces, or “exchanges,” will come on line in just over a year to help consumers who don’t have employee coverage at work find an affordable health plan that meets their needs. Third, a new category of eligibility for Medicaid was created for the lowest-income consumers, many of whom work in low-wage jobs that don’t come with health insurance, yet earn too little money to afford a private health insurance policy.

In June, the U.S. Supreme Court upheld the constitutionality of the Affordable Care Act but ruled that states could choose whether or not to implement that third component, the Medicaid expansion.

Covering the lowest-income uninsured through Medicaid will provide access to basic prevention and treatment services that uninsured Georgians lack today. A landmark study published last year by the National Bureau of Economic Research found that people who gained coverage through Medicaid were more likely to access preventive services and have a usual source of care than their uninsured counterparts. A study published in the New England Journal of Medicine found that states that expanded Medicaid saw lower mortality rates, even after taking into account a range of other factors, than their neighboring states who did not.

In other words, if you want to improve health care outcomes, expanding Medicaid is a proven way to accomplish this goal.

The benefits to Georgia of expanding Medicaid go far beyond the 650,000 uninsured Georgians who stand to gain coverage. Because the Medicaid expansion is financed almost entirely with federal dollars, an infusion of resources will be pumped into our state’s health care delivery system.

If Georgia expands Medicaid, we stand to draw down approximately $14.5 billion in federal funds over the six-year period between 2014 and 2019, according to an analysis by the Urban Institute. In fact, Georgia taxpayers are already contributing towards the cost of the Medicaid expansion. It’s just a question of whether some of that money comes back to Georgia or whether we leave it on the table and allow it to be diverted to other states.

Last week, Gov. Nathan Deal announced that he did not intend to move forward with the Medicaid expansion, expressing concerns about the federal government’s long-term fiscal outlook. Just last month, states received word that they have an important element of flexibility: They can implement the Medicaid coverage expansion and, after a few years, if it isn’t working for them, they can withdraw.

There is no reason why Georgia can’t take advantage of the tools and resources before us to invest in our state’s health care economy today  and revisit our participation periodically to ensure that the federal government is meeting its end of the bargain and that the program works.

We have an unprecedented opportunity to improve the health of Georgia patients and consumers, strengthen our state’s health care delivery system, and bolster the state’s economy by moving forward with the Medicaid expansion.

Georgia policymakers should seize the moment and invest in our future.

On Friday, July 13 the Georgia Department of Community Health (DCH) announced plans for next steps in the “Medicaid Redesign.”  Over the past several months, DCH has convened task forces comprised of stakeholders and advocates to formally provide input into this process. At the same time, advocates have come together as the CARE-M coalition to develop recommendations based on best practices for vulnerable populations. This redesign process is separate from but parallel to the conversations currently taking place regarding whether or not to move forward with implementation of the Medicaid expansion authorized by the Affordable Care Act. Ultimately, both processes will have a big impact on coverage and access to care for health care consumers throughout Georgia.  In a press release, DCH said:

“Today, the Georgia Department of Community Health (DCH) announced that it will move forward with implementing key recommendations from its Medicaid and CHIP (Children’s Health Insurance Program) Redesign task forces and workgroups. It will not, however, pursue wholesale restructuring of Georgia’s Medicaid program at this time because of increasing uncertainty at the federal level.”

According to DCH, the changes that the state will move forward with include: 

• Proceeding with at-risk managed care to serve Georgia Families members

• Transitioning children in foster care to one designated vendor statewide within the new Georgia Families program

• Maintaining Georgia’s current Fee-For-Service structure for ABD populations and services

• Moving forward with Home and Community-based Services Rebalancing. This rebalancing will help move patients from skilled nursing facilities to home and community based services.

• Begin utilizing a value-based purchasing model. Value-based purchasing will allow DCH to continuously improve the quality of care for our members while better engaging our providers and ultimately containing costs.

• Creating a one-stop portal will improve accountability and efficiency. Specifically the portal will give health care providers better information about their members and their medical history, streamline their credentialing process, and present providers with a measurement of key performance metrics and allow them to monitor quality and outcomes compared to their peers.

• Creating a Common Pharmacy Preferred Drug List that will simplify the program and reduce administrative burden on providers

The Department has committed to continuing its work with the task forces and work group through the RFP process and past the go-live date.  As members of the Children and Families Task Force and Substance Use and Mental Health Working Group, Georgians for a Healthy Future staff will continue to provide a consumer voice in these discussions and will continue to advocate for greater access to care for Georgia’s most vulnerable citizens.  For more information about the redesign process, visit https://healthyfutprod.wpengine.com/issues/medicaid-and-peachcare-redesign.

Georgians for a Healthy Future and the Georgia Council on Substance Abuse are embarking on a joint project on substance abuse disorder policy and its intersection with health care policy! This is a 10-month health care initiative supported by a grant from Community Catalyst to develop and advocate for a continuum of comprehensive services that address the needs of people at risk of and who have a substance use disorder. For more information about substance abuse programs visit altustreatment.com

Starting in January 2014, the Affordable Care Act will require insurers to cover treatment for drug addiction the same way they would other chronic diseases.  As one of the required essential health benefits, for the first time all those enrolled in Medicaid will have access to the substance abuse services they need. Check it out if you need any help from professional to threat addiction.

The Medicaid expansion authorized under the Affordable Care Act also holds a tremendous opportunity to reach segments of the population who were previously ineligible for services (such as childless adults up to 138% FPL). However, this is not a forgone conclusion–the state may decide to opt out of the expansion.

Georgia policymakers have not yet decided whether they will move forward with the Medicaid expansion. With 1 in 5 Georgians currently uninsured, the Medicaid expansion has the promise of providing an essential pathway to health insurance and health care for approximately 600,000 to 900,000 Georgians. It is critical that policymakers hear from the consumers and communities who need this very basic access to health care.

In the weeks and months ahead, Georgians for a Healthy Future and the Georgia Council on Substance Abuse will mobilize to ensure that Georgia implements the Medicaid expansion, but we cannot do it without your help.  To join our efforts, email Amanda Ptashkin.

For more information about this collaboration, click here.