Health care measure

The Gazette Editorial Board

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When Iowa lawmakers finally broke a session-long stalemate over expanding health insurance coverage for tens of thousands of low-income Iowans, the news was greeted with great bipartisan fanfare.

What looked like a gap too far to bridge in the final frantic days of the 2013 session, suddenly became a done deal. Gov. Terry Branstad signed it into law late last month.

And now that the confetti has settled, and we've had some time to examine that complex legislative work product more closely, it looks like - for the most part - those accolades were appropriate.

HOW IT WORKS

If all goes according to plan, on Jan. 1, the Iowa Health and Wellness program will provide health coverage to an estimated 150,000 Iowa adults with annual incomes below 138 percent of the federal poverty line, or about $16,000 for a single earner. Those making at 100 percent or less of poverty, or about $11,500, will be eligible for virtually the same insurance coverage received by state employees. Those between 101 percent and 139 percent will be allowed to purchase private insurance from an insurance exchange, with state subsidies covering all or most of the premium costs.

Iowa Health and Wellness replaces the Iowa Care program, which provided much more limited coverage to about 75,000 low-income Iowa adults. Iowa Care clients could seek treatment at only two hospitals in Iowa, in Des Moines and Iowa City, or at six community clinics scattered across the state, meaning long drives and long waits for care. It provided no or very limited access to dental and mental health care.

Under the new Iowa Health and Wellness plan, clients can pick a doctor close to home. Dental and mental health services, including substance abuse treatment, and vision screening will be available.

With those carrots, there are some sticks. After the first year of the program, recipients from 50-138 percent of poverty will be expected to meet preventive care and wellness objectives. If they meet those objectives, they'll continue to receive premium subsidies. If they fail, they'll be required to pay some share of monthly premiums.

“It's the most significant increase in health care coverage in Iowa since Medicaid,” said Sen. Jack Hatch, D-Des Moines, who was a key player in the Statehouse health care debate.

Details are still being worked out as the state seeks a federal waiver it needs to move ahead with Health and Wellness. The exchange is also still in the planning stages.

CAP PROBLEM

But between now and Jan. 1, there's a troubling gap that lawmakers created.

On July 1, the Iowa Medicaid Enterprise capped enrollment in Iowa Care. So between now and the end of the year, low-income adults in need of health coverage will be out of luck. Officials estimate roughly 700 Iowans each month, to 4,200 total, could be affected by the cap gap.

Local public health officials were notified of the change on June 20, just days before the cutoff.

“It was a big surprise,” said Cindy Fiester, chronic disease services coordinator for Linn County Public Health. The department is now scrambling to coordinate community resources to cover an estimated 300 county resident who otherwise would have qualified for the Iowa Care program.

Hatch admits that lawmakers failed to mind the gap.

“We did not object to that, apparently. We were so consumed with getting Medicaid expansion passed, and the budget, that we never had a time to really examine what that would mean,” Hatch said. “And that was a mistake.”

Iowa Medicaid Director Jennifer Vermeer said her department sought the cutoff to avoid problems she contends would have been caused by allowing new enrollments during the transition to a new program. She argues that Iowa Care providers are already stretched to the limit, and that care delays would have meant continuity of care problems for patients.

“For all of those reasons, capacity issues, logistical issues, transition of care issues, continuity of care issues, we felt it was just better to not enroll new members for the period of six months,” Vermeer said, adding that the governor and lawmakers provided no dollars for new enrollees.

Hatch also blamed inadequate staffing within the department to handle the transition. He contends the Legislature approved funding for staff that was vetoed by Gov. Terry Branstad.

FIX THIS MISTAKE

Whatever the reason, we think this gap was a big mistake. Although we understand the challenges of turning a vast bureaucracy in a new direction, those issues pale in comparison to the needs of sick Iowans seeking help. It's not a large number of people in the big scheme of government entitlements, but if a small Iowa town of 4,200 was in trouble, it's plight would make front page news and likely prompt a large-scale response.

And evidence shows that those seeking Iowa Care are often sick - in some cases, very sick.

According to a survey of Iowa Care recipients by the Public Policy Center at the University of Iowa, 60 percent of respondents reported three or more chronic conditions and 40 percent rated their health fair to poor. The survey found that Iowa Care recipients tend to be sicker overall than average adult enrolled in Medicaid.

“Among the uninsured, these are going to be among the sicker ones,” said Peter Damiano, who directs the policy center. He said many Iowa Care clients find the program after they become ill.

We commend county officials for responding as quickly as possible to the coverage gap. And we urge state human services leaders to provide emergency resources to help that effort. Hatch says lawmakers could pay for that emergency help when they return in January. That makes sense.

The good news in Damiano's survey is that the Iowa Health and Wellness program will address many of the concerns expressed by Iowa Care recipients. One-third of recipients rated their mental/emotional health as fair to poor and 61 percent applied the same fair to poor label to their dental health. A sizable number of those surveyed expressed dissatisfaction with access to health care.

PREVENTION AT RISK

Also, less than one half of respondents had received preventive care in the last six months.

Damiano said preventive care incentives included in the new Health and Wellness plan could have a positive impact in keeping some clients from developing chronic conditions. But he doubts it will lead to big cost savings.

“That's not to say prevention isn't a good thing and that we shouldn't be promoting it. But the real cost savings are in other ways of dealing with people with severe chronic illnesses,” Damiano said.

The state will attempt to control those costs through the formation of Accountable Care Organizations, or ACOs, to corrdinate client care with an eye on outcomes and costs.

But it's doubtful that federal officials will allow the state to charge any premiums to Iowans below the poverty line.

“They didn't tell us that wouldn't be accepted. But we're all very clear they have not approved those in the past,” Hatch said, adding that he thinks lawmakers will resist the idea of promoting preventive care if the feds balk.

“We may need to be a little more creative in how we get people to do that.”

We hope the federal government leaves the prevention and wellness incentives in place as a strategy that may have long-term benefits. But we agree with Hatch that lawmakers should work on a new approach in case those requirements are rejected.

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