While the Center for MEdicare Advocacy continues to press for systemic improvements to the Medicare program, both big and small, there has been some good news for beneficiaries in the health care arena. As calendar year 2014 draws to a close, the Center highlights positive changes in Medicare and health care that occurred this year, drawing the country closer to our goal of health care for all. We start with some structural, big-ticket items then reference some smaller but nonetheless important policy updates to the Medicare program. Please send us additions for our list!
Implementation of the Affordable Care Act (ACA), aka Obamacare, Has Helped Extend the Medicare Trust Fund By More Than 10 Years
Since 1970, the Medicare Trustees have projected the Medicare Trust Fund would be insolvent in as little as four years or as much as twenty-eight years. The longest projected solvency period occurred in years in which the country experienced high economic growth and budget surpluses.
According to a Kaiser Family Foundation Issue Brief, How Much of the Medicare Spending Slowdown Can be Explained? Insights and Analysis from 2014, the Medicare Trustees extended by more than 10 years their projections of the solvency of the Medicare Hospital Insurance trust fund, from 2017 (2009 projection) to 2030 (2014 projection).
Medicare Costs Continue to Decline
According to the Kaiser Family Foundation, Medicare spending has been extraordinarily low relative to historical norms. Annual growth in aggregate spending has averaged just over 3 percent since 2009, despite rapid enrollment growth due to the aging of the “Baby Boom” generation.
The Kaiser Family Foundation Issue Brief, How Much of the Medicare Spending Slowdown Can be Explained? Insights and Analysis from 2014, examined spending in 2014 ($580 billion) relative to the Congressional Budget Office’s (CBO) 2009 projections ($706 billion) and the factors related to lower-than-expected Medicare spending in 2014. The Issue Brief found that about half of the change was the result of deliberate policy actions through the enactment of the ACA and the Budget Control Act (BCA). Together, these laws were projected to reduce Medicare spending on net by $65 billion in 2014, based on CBO estimates at the time.
Even after taking the savings attributed to the ACA and BCA into account, however, Medicare spending is still far lower in 2014 than CBO projected it would be in 2009. The Issue Brief stated that, while several likely factors exist for the additional savings over the CBO projection, definitive reasons are difficult to establish at this point. Some of the possible reasons cited by the paper include: unanticipated effects of changes in Medicare policy (i.e., lower hospital readmissions, lower home health spending, higher recoveries from providers); and reductions in Medicare payment rates leading to reduction in utilization.
Implementation of ACA Has Led to Health Insurance for Many More People
- A Special Report in the New England Journal of Medicine, “Health Reform and Changes in Health Insurance Coverage in 2014,” found that the number of Americans without health insurance declined significantly since the ACA open-enrollment period began in October 2013. “As compared with the baseline trend, the uninsured rate declined by 5.2 percentage points by the second quarter of 2014, a 26% relative decline from the 2012–2013 period. Combined with 2014 Census estimates of 198 million adults 18 to 64 years of age, this corresponds to 10.3 million adults gaining coverage, although depending on the model and confidence intervals, our sensitivity analyses imply a wide range from 7.3 to 17.2 million adults.” The complete report is available at: http://www.nejm.org/doi/full/10.1056/NEJMsr1406753
- An article in the New York Times describes the breakdown of who has benefited from ACA (from those covered in 2014, the analysis was conducted prior to 2014 open enrollment period. The full article is available at: http://www.nytimes.com/interactive/2014/10/29/upshot/obamacare-who-was-helped-most.html?_r=0&abt=0002&abg=0
- A CMS report states that the number of uninsured is expected to decline by nearly half from 45 million in 2012 to 23 million by 2023 as a result of the coverage expansions associated with the Affordable Care Act. More information is available at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-ions of Litems/2014-09-03.html
IMPORTANT POLICY UPDATES
Here we highlight a few of the many changes that improve the lives of Medicare beneficiaries and their families.
The Centers for Medicare & Medicaid Services (CMS) Is Implementing United States v. Windsor to Recognize Marriage Equality in Its Administration of Federal Health Care Statutes and Programs
CMS is implementing the decision in United States v. Windsor, 570 U.S. 12 (2013), which declared unconstitutional Section 3 of the Defense of Marriage Act (DOMA). DOMA defined marriage as a union of one man and one woman. In revisions to interpretive guidance for hospitals, psychiatric hospitals, hospice, long-term care facilities, critical access hospitals, and organ procurement organizations, CMS clarifies that the terms “spouse,” “marriage,” and related terms “include all marriages lawful where entered into, including lawful same-sex marriages, regardless of the certified provider’s or supplier’s location or the jurisdiction in which the spouse lives.”
In further implementation of Windsor, CMS published proposed regulations for other health care providers “to ensure that these valid same-sex marriages are treated on the same terms as opposite-sex marriages in these Federal programs.”
CMS is improving accuracy of the federal website and the Five-Star Rating System for nursing facilities
In October, the White House and CMS announced major changes to Nursing Home Compare, the federal website for nursing facilities, and the Five-Star Rating System. With funding provided by the Impact Act of 2014, CMS will implement a payroll-based electronic reporting system so that staffing levels reported on Nursing Home Compare are accurate. In addition, it will include antipsychotic drug rates in the quality measure portion of the Five-Star Rating System; conduct focused surveys nationwide to improve staffing and quality measure information; ensure that States maintain user-friendly websites and complete timely inspections of facilities; and revise the scoring methodology for Nursing Home Compare.
Hospice Patients Saw Their Rights Expanded
As part of the "Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), hospice surveys will now be conducted every three years. More frequent surveys will help ensure that hospice patients get enough care and the right kind of care.
In addition, requirements for the hospice election form were changed. Historically, many hospice patients did not realize that they had a right to choose their own attending physician. Now-mandatory language on the election form, in combination with the requirement that hospice providers inform their patients verbally and in writing that they have a right to choose their own attending physician, should mean that more hospice patients exercise this very important right.
Finally, a March 2014 Guidance from CMS that would have required prior authorization for all drugs prescribed to a beneficiary who elected hospice was replaced. The replacement guidance, issued in July, states that Medicare Part D plans should continue to fill medications as they were filled prior to hospice election, with the exception of analgesics, antiemetics, laxatives, and anxiolytics. These four categories continue to have prior authorization requirements imposed upon them because they are usually related to palliative treatment for the terminal illness and related conditions, and thus are usually, (but not always) covered as part of the Medicare hospice benefit.
2015 GOOD NEWS PREVIEW
Medicare Starts Paying for New Chronic Care Management Services in 2015
As noted by CMS, “Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – beginning in 2015. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.”
More information is available at: http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2014-Fact-sheets-items/2014-10-31-7.html
Medicare and Medicaid Turn 50
2015 marks the 50th anniversary of Medicare and Medicaid. Each of these programs has become an invaluable safety net for our older and vulnerable citizens. These programs should be protected and expanded.
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 The complete issue brief, How Much of the Medicare Spending Slowdown Can be Explained? Insights and Analysis from 2014, is available at: http://files.kff.org/attachment/issue-brief-how-much-of-the-medicare-spending-slowdown-can-be-explained-insights-and-analysis-from-2014.
 CMS, “Clarification of Terms Implicating the Spousal Relationship in Regulations and Guidance for Medicare- and Medicaid-certified Providers and Suppliers,” S7C: 15-13-ALL (Dec. 12, 2014) (Memorandum from Thomas E. Hamilton, Director, Survey and Certification Group, to State Survey Agency Directors), http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-13.pdf.
 79 Fed. Reg. 73873, 73874 (Dec. 12, 2014), http://www.gpo.gov/fdsys/pkg/FR-2014-12-12/pdf/2014-28268.pdf.
 See “Administration Plans Major Improvements to Nursing Home Compare” (Weekly Alert, Oct. 16, 2014), https://www.medicareadvocacy.org/administration-plans-major-improvements-to-nursing-home-compare/; “Changes to Nursing Home Compare: Some Good, Some Bad” (Weekly Alert, Nov. 20, 2014), https://www.medicareadvocacy.org/changes-to-nursing-home-compare-some-good-some-bad/
 Text of the IMPACT Act can be found here: https://www.govtrack.us/congress/bills/113/hr4994.
12/17/14 – T. Edelman