Medicaid reaches more

Maryland is patching together expanded coverage for the low-income uninsured

By Laura Smitherman

Sun reporter

July 1, 2008

Insuring the uninsured

Our view: Health of Maryland's poor gets a needed boost this week

June 29, 2008

Joanne Hohman is slowly losing the use of her knees but can't afford a specialist to diagnose exactly what's wrong. Her husband, Richard, recently suffered chest pains and may have sleep apnea but can't pay for the test to confirm it.

Living on less than $20,000 a year, the middle-aged Catonsville couple has been forced to neglect a variety of ailments, from high blood pressure to asthma. They are two of the estimated 800,000 Maryland residents who lack health insurance of any kind.

But their health is due to change for the better after Tuesday.

That's when Maryland's landmark expansion of Medicaid goes into effect. Eventually, more than 100,000 uninsured people will qualify for some type of health care under the legislation passed by the General Assembly last year.

The Hohmans' 13-year-old son already receives help from the federally supported medical assistance program, but now his parents will be able to enroll, too. Maryland's Medicaid program has long been geared toward helping children in poverty, but this has also been one of the stingiest states in the nation when it comes to providing care for their parents.

Even with the change, it's still far from a bonanza. Eligibility standards for poor adults will now rank somewhere around 21st in the nation, health care advocates say, but it's a distinct improvement from Maryland's former position in the bottom five. The new law also provides premium subsidies and other benefits to small employers who haven't been able to provide health insurance to their workers.

Obviously, this is no cure-all for the many woes of the health care system. Medicaid has become a huge expense, and other avenues, such as requiring private health insurance for those who can afford it, will also have to be pursued.

But for the working poor like the Hohmans, this is a godsend. And when critics of Gov. Martin O'Malley and the legislature grouse about expanding government, they ought to be reminded of the reasonable health care benefits our most vulnerable families are getting in return.

Nizar Dowla was not thinking about paying for health insurance when he entered the University of Maryland, College Park.

Now, as a 20-year-old junior considering medical school, Dowla will be able to put off worries of paying for his own insurance for a few more years under a new state law requiring insurers to allow young adults to remain on their parents' health insurance until they are 25.

‘‘To be honest, I wasn't really thinking about this at the beginning of college, but now that I'm a junior entering senior year, you kind of see the light at the end of the tunnel,” said Dowla, who is president of the university's Student Health Advisory Committee.

For some, that light is a freight train full of expenses.

Whether they are considering postgraduate study or entering the work force, tuition, loans and health care costs are major considerations for students about to leave college.

The new law will make things a bit easier, said Dowla, who stands to save $7,500 over the first three years of medical school by remaining on his father's insurance plan.

‘‘While they're getting situated, this is one less thing that students have to worry about,” he said.

Over the past two years, the General Assembly has taken steps to expand health care to the uninsured, from providing subsidies for small business to expanding Medicaid coverage to 100,000 uninsured Marylanders.

Last week, health care advocates held news conferences at Towson University and at College Park highlighting the new law.

Passed in 2007, the Family Coverage Expansion Act began applying to health insurance coverage on Jan. 1, making this semester's students the first wave of college graduates to benefit from the initiative.

‘‘This is the same time that last year if they were graduating from college they would be dumped,” said Vincent DeMarco, president of the Maryland Citizens' Health Initiative.

Before the act passed, state law required insurers to cover dependent children through the end of the year in which they turned 19. Dependent children who were disabled or full-time students were able to retain their coverage until they turned 23.

Advocates do not know how many of the estimated 100,000 people between 19 to 23 are uninsured, said DeMarco, adding that a ‘‘fair” estimate is that the new law will benefit ‘‘tens of thousands.”

‘‘It shows a dedication by our lawmakers to make sure young people are healthy, have health care and have access to preventative measures to make sure they stay healthy,” said Andrew Friedson, student body president at College Park.

‘‘Losing insurance coverage used to be a dangerous rite of passage for thousands of young people graduating from high school or college,” said Del. Heather R. Mizeur, who sponsored the expansion legislation.

The law will protect young people who often have to choose between relying on their parents to pay for an individual plan or ‘‘play Russian roulette” and risk not having health coverage, said Mizeur (D-Dist. 20) of Takoma Park.

‘‘We're giving a certain level of economic security for the entire family,” she said. ‘‘No family is going to be burdened by a catastrophic health incident.”

The bill also allows employers, not insurers, to decide whether to extend health care benefits to domestic partners.

‘‘If an employer wants to provide domestic partner coverage for a family, they get to now,” Mizeur said.

The law is the first of several passed in the past two years to expand health care.

During last fall's special session, despite grappling with a $1.5 billion budget deficit, legislators approved expanding Medicaid to parents of children enrolled in the Maryland Children's Health Program and uninsured adults with incomes at 116 percent of the federal poverty guidelines, or $11,844 a year.

This year, the General Assembly passed legislation to expand children's dental care and to help senior citizens who fall into Medicare's ‘‘doughnut hole” where they are forced to pay the full cost of prescription drugs.

‘‘Across age, economic and geographic - any kind of demographic in Maryland - health care has been improved under the O'Malley administration,” DeMarco said.

Advocates are closely monitoring a showdown between the Bush administration and several states, including Maryland, over Medicaid funding.

The administration is proposing new rules that would reduce what it sees as $13 billion in fraudulent or unnecessary expenditures. Maryland officials say the changes will take tens of millions of dollars from a pregnancy program, rehabilitation and outpatient care and other programs.

‘‘The Bush administration's proposed Medicaid regulations would be disastrous,” DeMarco said. ‘‘It would be terrible for kids on Medicaid and terrible for all of us by putting more people in hospitals for our care. We commend Congress for doing everything it can to overturn these draconian measures.”

In the meantime, advocates are trying to ensure that everyone who can be covered is.

‘‘The next step right now is to make sure everybody who's eligible for these new programs is enrolled,” DeMarco said.

Another bill sponsored by Mizeur that passed the General Assembly this year requires the state to send application packets to low-income taxpayers whose dependents are eligible for the Maryland Medical Assistance Program or the Maryland Children's Health Program.

‘‘All of that being said, we've got a lot of implementation going on right now,” Mizeur said.

‘‘Eventually we will be talking about expanding health care more, but we're not talking about that right now,” DeMarco said.

For now, the talking is being left to participants in a series of 13 town hall meetings that the Maryland Citizens' Health Initiative and Progressive Maryland are holding around the state. Participants are being given information about new health care programs and laws and are being asked for input on ways to expand coverage that will be pushed during the next year's General Assembly.

Amid tough economic times, the state should continue to look at forging public-private partnerships through nonprofit insurers, Mizeur said.

The state, facing a continued budget deficit and an economic downturn, needs to get its finances in order before looking to spend more on health coverage, said House Minority Leader Anthony J. O'Donnell.

‘‘In my opinion, we cannot continue to spend taxpayer dollars that we don't have,” said O'Donnell (R-Dist. 29C) of Lusby. ‘‘Unless we want to throw in the towel and move to a socialized system, I think it's a bad idea.”

In the meantime, others are finding ways to expand coverage.

Howard County plans to enroll 2,000 people beginning in July in a partnership between the county, nonprofit and for-profit health care providers and Howard County General Hospital. The county hopes to ultimately cover up to 20,000 uninsured county residents.

In March, the University Senate at the University of Maryland, College Park approved a policy requiring that new undergraduates show proof of health insurance or purchase university policy.

The state and the university are moving in the right direction, Dowla said.

By M. William Salganik
Sun reporter

February 7, 2008

Maryland Citizens Health Initiative is refueling for the next phase of its campaign for universal health insurance in the state with the announcement yesterday that it is receiving a three-year, $250,000-a-year grant.

The money comes from the Robert Wood Johnson Foundation, a health-focused grant-maker in New Jersey. It is part of a $15 million, 12-state effort called Consumer Voices for Coverage.

"The purpose of this program is to strengthen advocacy efforts in states to expand health coverage," said Lori Grubstein, program officer for the foundation.

Vincent DeMarco, president of the Maryland group, said his organization is currently revising its 2002 "health care for all" plan and will use the grant for "coalition building."

That will mean the hiring of five to 10 organizers, supplementing the current staff of four, to seek support from community, religious and labor groups around the state.

Formed in 1999, the initiative developed its first universal coverage plan in 2002 and persuaded about 2,000 community groups to be supporters. The initiative has been operating on a budget of about $500,000 a year, mostly grants from local and national foundations, DeMarco said.

Parts of the 2002 plan have been enacted. This past winter's legislative special session approved a Medicaid expansion to cover more low-income adults starting in July and set up a program to provide financial help to small employers who haven't been able to offer health coverage to their workers.

For the next several months, DeMarco's organization will work to enroll people newly eligible for Medicaid (those who make up to 116 percent of the federal poverty level, or $24,492 for a family of four). Although about 250,000 of the state's 750,000 uninsured will be eligible for Medicaid coverage, the state expects only about half of them to sign up, DeMarco said.

Another piece of the initiative's 2002 plan, the so-called Wal-Mart bill, requiring large employers to offer adequate coverage or pay a fee to the state, was enacted in 2006 only to be blocked by a federal court.

With the Medicaid expansion in place, DeMarco said the plan would likely focus on how to reach 500,000 or so uninsured Marylanders who are not poor enough to qualify for Medicaid but can't afford health insurance, which costs about $10,000 a year for family coverage. He said the revised plan should be ready by May.

Lisa Rein
Washington Post Staff Writer

Friday, November 23, 2007; Page B01

Bills to insure 100,000 people, put $50 million toward Bay pass in special session’s final hours

The $200 million health care initiative will rely in the first year on money redirected from the Maryland Health Insurance Plan and on dedicating a doubling of the cigarette tax to $2 per pack.

It increases Medicaid eligibility to people with annual incomes of up to 116 percent of the federal poverty guidelines, or $11,844 a year.

‘‘This is great for the uninsured and it’s great for the rest of us also because we all pay for the hospitalization of the uninsured,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative.

The plan also provides $20 million to help businesses with two to nine low-income employees provide health care. A Senate committee cut a $10 million subsidy to boost health coverage for businesses already providing some coverage.

Lawmakrers also voted to include $20 million in the current fiscal year’s budget to help keep Prince George’s Hospital Center afloat.

The funding is contingent on the Prince George’s County Council, County Executive Jack B. Johnson (D) and the state coming to an agreement on the hospital’s future.

The House of Delegates held off on the health care bill until delegates voted on slot machine gambling. The slots plan passed early Sunday morning, leaving delegates to focus on health care. The expansion plan passed 104-28 early Monday morning.

The expansion plan creates a foundation for extending health care to all, DeMarco said.

‘‘The importance of this bill is that it takes Maryland from being one of the worst for providing health care for adults to one of the states at the forefront of health care reform,” he said.

Health care advocates do not plan on pursuing any new expansion legislation during the 2008 session, DeMarco said. They will work with the state to make sure people who are eligible for Medicaid get enrolled. They also will work with experts from the Bloomberg School of Public Health at Johns Hopkins University to develop a plan for universal health care expansion that they hope to announce next year.

More work also lies ahead for environmental groups, who cheered the passage early Monday of $50 million dedicated to Chesapeake Bay restoration.

‘‘Within a tough fiscal environment, that the Maryland state legislature said the bay and restoring it is a top priority for us, we’re standing and applauding their commitment,” said Kim Coble, Maryland executive director of the Chesapeake Bay Foundation.

Senate President Thomas V. Mike Miller Jr. (D-Dist. 27) of Chesapeake Beach proposed the funding earlier this month as an alternative to the ‘‘green fund.”

That bill, which died in the Senate earlier this year and was resurrected for the special session, went through several iterations. The version proposed before the special session would have paid for Bay restoration by taxing existing development.

The funding plan passed Monday uses $13 million from the state’s 23.5-cent-a-gallon gasoline tax and $37 million from an 11.5 percent car rental tax.

To the delight of environmental groups, lawmakers decided against a Senate plan that would have used $30 million from the vehicle titling tax and $20 million from the state’s Program Open Space program.

While the funding is in place, how it is spent will be an issue when lawmakers return in January.

Time ran out on the special session before the Senate could take up a bill that would have set aside 30 percent of the $50 million in spending for improving agricultural practices and 30 percent for local governments to improve stormwater management practices.

The rest of the funding would have been allocated at the discretion of the BayStat’s program implemented by O’Malley to monitor Bay health and restoration efforts.

Environmental groups will work with BayStat and use the failed bill as framework for legislation that they will push for next year, Coble said.

Along with an existing ‘‘flush tax” added to water and sewer bills for wastewater treatment system upgrades, the new Bay funding will get Maryland 70 percent to 80 percent toward a federal deadline to reduce nitrogen levels in the bay by 2010, she said.

Legislators tie part of bill to approval of slots

By Laura Smitherman
Sun reporter

November 19, 2007

The General Assembly approved legislation early this morning aimed at reducing the ranks of residents without health insurance in Maryland, advancing a measure championed by advocates as the first step toward confronting a lack of access to medical care.

The House and Senate approved a bill that would provide coverage to more than 100,000 when fully implemented in five years, sending the measure to Gov. Martin O'Malley for his signature. The bill expands eligibility for Medicaid, the federal-state health insurance program for the poor, and extends subsidies to as many as 37,000 small businesses to help offset the cost of offering insurance to employees.

Passage of the bill sought by O'Malley would put Maryland in league with other states addressing health care, an issue that's risen to the forefront of politics. The Maryland effort still falls short of other state programs that aim to provide universal health coverage, but O'Malley has said he would continue to push toward that goal. About 800,000 state residents, or 14 percent of the population, lack health insurance.

"This is a significant step forward for the state of Maryland in reforming its health care system," said Del. Peter A. Hammen,µ chairman of the House Health and Government Operations Committee. "Is it costly? Yes. But is it worth it? Absolutely."

The expansion of government-funded programs, which would eventually cost more than $600¤million a year, including $250¤million in state funding as well as federal matching dollars, had been mired in questions over whether the state could afford it. Legislators have been meeting in a special session to fix a projected budget shortfall of $1.7 billion.

Late last night, legislators agreed to add language to the bill sought by the Senate and intended to ensure that part of the Medicaid expansion happens only if voters approve slot machine gambling through a constitutional amendment on the November 2008 ballot. O'Malley envisions using slots revenue to help pay for the expansion.

O'Malley pledged that the expansion would have a pay-as-you-go feature, and the final bill also includes language that allows the administration to cap enrollment or limit benefits for childless adults if funding isn't available.

Senate President Thomas V. Mike Miller declined during the regular session this year to take up a similar health care bill that passed the House, noting budget concerns. His chamber did pass a version of the latest health care bill more than a week ago, but Miller warned that final approval would depend on passage of other revenue-raising measures.

House Speaker Michael E. Busch, a chief advocate for expanding coverage, postponed action on health care in the past week until his chamber acted on bills allowing slots if voters ratify the idea in a referendum. The House finished work on its slots bills early yesterday.

With 47 million Americans lacking health insurance and costs rising, health care has become the political watchword. Presidential candidates have unveiled their varying plans to expand coverage. And 28 states have considered measures on health care reform, said Richard Cauchiµ of the National Conference of State Legislatures.

Oftentimes, budgetary considerations have shaped the debate. Tennessee and Indiana have approved expansions this year, but their efforts don't call for the universal coverage envisioned by Massachusetts and Vermont, which passed more comprehensive plans in 2006.

Some House Republicans objected to increasing spending at a time of fiscal crisis. Del. Adelaide C. Eckardt, a GOP member from the Eastern Shore, failed to amend the bill to make it "revenue neutral," meaning it would be paid for by curtailing benefits or increasing cost sharing by Medicaid beneficiaries.

"Medicaid is one of the fastest-growing budgets we have not only in this state but in the country," Eckardt said. "This is the right bill at the wrong time."

Under Maryland's Medicaid expansion, adults earning up to 116 percent of the federal poverty level, or about $20,000 a year for a family of three, would be eligible. Maryland covers children in families earning up to three times the poverty level, but the state has a much lower threshold for covering adults -- about 40 percent, or about $5,000 a year.

The bill includes $30 million in annual subsidies for small businesses with fewer than 10 employees as well as their employees. The subsidy is contingent on the employer offering a wellness benefit. The bill also includes funding for the troubled Prince George's Hospital Center.

Some revenue would be redirected from the state's uncompensated-care fund, which reimburses hospitals in the state for treating the uninsured to pay for the expanded eligibility. Backers of the expansion say that residents with private insurance would save money because the cost of treating the uninsured is passed on through higher rates charged by hospitals, which is built into insurance premiums.

An expansion in Medicaid could help residents like Barbraµ Lancelot of Silver Spring, who has been without insurance for six months since health problems forced her to leave her job. While she is navigating state bureaucracy to determine if she is currently eligible for Medicaid, she may earn too much money through part-time work to qualify.

"When health insurance disappears, things can get bad pretty fast," said Lancelot, who is on nine prescription medications. "I just hope nothing happens to me that I have to go to the doctor or hospital. People just don't realize how difficult it is, how precarious it is. One illness and you could be in my situation."

Vincent DeMarco, who has been lobbying on the issue since 1999 and serves as president of the Maryland Citizens' Health Initiative, said: "This is a great day for working families of Maryland."

Reform could be linked to budget deficit package

By Laura Smitherman
Sun reporter
April 16, 2007

The Maryland General Assembly adjourned without approving a multimillion-dollar plan to expand health care coverage to thousands of state residents, but the proposal remains on the table and the drumbeat for universal coverage is only expected to grow louder until lawmakers meet again.

The debate over how to help the growing number of uninsured, a costly dilemma that politicians across the nation are struggling to address, will once again butt up against Maryland's projected $1.5 billion budget shortfall in the next session. But lobbyists and lawmakers say the two issues could work in tandem, with health care as a sweetener in a potentially unpalatable tax package.

Just days after lawmakers departed Annapolis, the idea of a large legislative package is being floated. Such a package would close the budget gap and could include other programs that could be used to draw votes, including transportation funding, the legalization of slot machines and a revamping of the state's outmoded tax structure.

"It makes the sale of a tax package easier," said Sen. Thomas M. Middleton, a Charles County Democrat and chairman of the powerful Finance Committee, where the expansive health care proposal died this session. "It would be a whole lot less offensive for taxpayers if they know part of the funding is going to a health care expansion."

While the legislature did pass some health care legislation, including a measure requiring that insurers cover adults up to age 25 on their parents' policy, they did not approve an expansive proposal to bring more of the state's nearly 800,000 uninsured under Medicaid, the government insurance program for the poor. That plan, which passed the House of Delegates but not the Senate, is considered a blueprint for legislation in the next session.

The rising price of health care has made it a potent political topic, and the possible closure of Prince George's Hospital Center, which has suffered financially as it has cared for a large number of uninsured patients, has underscored the problem. Lawmakers and health care advocates say the number of Marylanders without health insurance could increase by 50,000 in the next year.

Laying groundwork

"What this session did was lay the foundation for a substantial health care expansion in Maryland, and I think that's going to happen the next time the Assembly meets," said Vincent DeMarco, president of the Maryland Citizens' Health Initiative, which has been lobbying for years on the issue. "The Prince George's County hospital disaster illustrates the need for health care coverage."

Gov. Martin O'Malley, who made affordable health care a priority after taking office in January, said he would continue to work with state leaders on finding ways to expand medical coverage but stopped short of endorsing any specific plans for the next session.

"One of my bigger disappointments in the session is that we didn't do more," O'Malley said.

Sweeping health care proposals have been introduced in several state legislatures, including in Pennsylvania, Illinois and California, often running into cost concerns.

"There are a number of states that are going to have a very serious run at expanding coverage," said Ron Pollack, executive director of Families USA, an advocacy group. "This issue is being catapulted toward the top of the domestic agenda."

The debate mirrors one taking place in the nation's capital. Congress wants to expand the government-subsidized insurance program for children in lower-income families, while President Bush has proposed curtailing it as part of a budget-balancing plan.

In Maryland, the financial demands are staggering. In addition to the deficit, health care plans could require as much as $400 million a year in state funds and transportation needs could reach $600 million annually. Even if slots were approved, bringing in as much as $800 million a year in revenue, the amount of money that needs to be raised is significant.

House Speaker Michael E. Busch said health care should take precedence as Maryland lawmakers face difficult choices on how to fund pressing issues. He expressed skepticism of a wide-ranging package, saying the logistics would be "daunting."

"The health care problem isn't going to go away; it will only become more of an issue with the average constituent," said Busch, a Democrat from Anne Arundel County. "It's just as pressing a problem as transportation, as our education system."

Busch pushed hard for a bill that would have extended Medicaid to more than 100,000 residents; it passed the House with broad support. The bill fell to opposition in the Senate, where Senate President Thomas V. Mike Miller took issue with the bill's main funding source, a doubling of the tobacco tax to $2 per pack of cigarettes.

Miller, a Democrat who represents Calvert and Prince George's counties, has warned colleagues that a painful budget-balancing process is imminent, and that lawmakers may need to return for a special session before next year. He has said the legislature would eventually address health care but that confronting the state's structural deficit is paramount and may require a number of solutions, including budget cuts, tax increases and slots.

Even the tobacco tax remains an option. While O'Malley and Miller said the tax would be an inappropriate revenue stream for health care because it declines as fewer people smoke, lawmakers left open the possibility of raising it to shore up the general fund.

The main thrust of any health care fix is likely to be an expansion of Medicaid for adults; the state's program already covers children in families earning up to three times the poverty level ($20,650 a year for a family of four).

The failed House bill would have tripled the maximum allowable income for Medicaid coverage for adults to about $12,000 a year for individuals, or about 115 times the poverty level, at a cost of roughly $200 million a year in state funds.

Proposals, including one from O'Malley, to raise the eligibility threshold for children have met with concerns about the "crowding-out effect." That means people drop their employer-provided insurance programs to enroll their children in Medicaid, which requires participants to pay a sliding-scale premium at higher income levels that is typically cheaper than private insurance.

Health care bills

The legislature did pass several less-expansive bills on health care in the latest session.

One measure, also included in the O'Malley proposal, requires that private insurers and the health plan for state employees allow adults up to age 25 to stay on their parents' plan, and that insurance policies cover domestic partners and their children.

Other legislation authorizes health insurers to provide discounts to small employers that participate in wellness programs, including smoking cessation plans and nutrition education, and would encourage new types of insurance products for seasonal and part-time workers.

"I wouldn't look at the session as a complete loss for health care progress," said Ronald W. Wineholt, a lobbyist with the Maryland Chamber of Commerce who worked on health care legislation. "There were some small steps that were taken that I think will prove helpful."

Another bill calls for a study of so-called individual mandates, under which residents must obtain health insurance or face financial penalties, as well as employer mandates that would force businesses to provide health plans for workers.

Some of the proposals slated for study could be part of legislation in the next session, and are aimed at getting people insured who may not be eligible for Medicaid.

Lawmakers were surprised by the findings of past study groups. For instance, people who make more than four times the poverty rate, or about $80,000 for a family of four, comprise about 25 percent of the uninsured. Also, more than half of Maryland's uninsured are working adults. And those aged 19 to 29 are the least likely to have insurance coverage through an employer, with an uninsured rate of about 28 percent.

"We'd like to see a multifaceted package that's not limited to a Medicaid expansion," said Nancy Fiedler, senior vice president of the Maryland Hospital Association. "We'd still like to go back and have the broader discussion."