Volume 29, Issue 516 May 27, 2008

CONTENTS

State News • Iowa Takes an Incremental Approach to Universal Coverage • More Churches Start Paying For Health-Care Services, Leaving States To Confront The Question: Are These Groups Insurers? • "Silver Alerts" Sound the Alarm When Certain Seniors Go Missing

Highlights A Google provides online health records…Monitoring brain injuries in veterans…Treating autistic adults

Graphically Speaking The number of Americans using health savings accounts has nearly doubled in the past two years with growth highest in the small group market.

STATE NEWS

IOWA TAKES AN INCREMENTAL APPROACH TO UNIVERSAL COVERAGE

Anna Wolke

When Governor Chet Culver signed a comprehensive piece of health reform legislation (HF 2539) this month, Iowa joined the growing contingent of states reaching for statewide health-care coverage.

The law calls for covering all children in part by expanding SCHIP, studying methods for making health care accessible to all adults and developing recommendations for advancing health information technology.

A distinctive feature of Iowa's reform is its incremental and decidedly bipartisan nature. Representative Ro Foege, who helped champion the bill in the House, commented, "It truly was a bipartisan effort, or we couldn’t have passed it. In the House [and the Senate], there were only a handful of votes against it on final passage, which says a lot for a major bill."

"We spent 18 months on the consensus part of the health bill so all parties could come to the table and no ideas were viewed as being new or being sprung on the Committee on Human Resources," said Representative Linda Miller. "All groups had time to work out disagreements and find constructive approaches."

The legislation lays out plans to gradually cover every uninsured child in the state, reaching universal coverage for children by 2011. The law will achieve this partly by expanding its SCHIP, hawk-i, to include children from families earning up to 300 percent of the federal poverty level. Prior to this law, eligibility levels for hawk-i were set at 200 percent of poverty.

Lawmakers foresaw that they could have difficulty in expanding SCHIP to children with incomes above 250 percent of poverty, in part because of recent federal actions. The federal SCHIP law has not been reauthorized and on Aug. 17, 2007, the Centers for Medicare & Medicaid Services (CMS) sent out guidance that appears to prohibit SCHIP coverage of children with incomes above 250 percent of poverty. CMS issued a follow-up letter on May 7, 2008, meant to clarify the August 17 directive and demonstrate a willingness to work with states on the issue (see SHN #515). Congress recently included a provision in the supplemental war funding bill that would place a moratorium on the August 17 directive until April 1, 2009. The bill has passed the Senate, and the House is expected to vote on the measure this week.

To deal with these obstacles, Iowa's new law stipulates that, if the federal government reauthorizes SCHIP so that it provides enough funding to cover children up to 300 percent of poverty, and if the federal government provides "authorization" to cover these kids (i.e., negates the Aug. 17 guidance), the state will begin expansion using the federal SCHIP match to expand hawk-i. "However, [in HF 2539] the legislature appropriated $25 million to expand hawk-i to 300 percent of poverty and we have instructed the SCHIP board to prepare for the expansion. We hope that the issue over the August 17 guidance is resolved by Congress but we are also prepared to proceed with state-only funds," said Senator Jack Hatch.

Children between 200 and 300 percent of poverty will receive coverage under hawk-i, but will likely be subject to higher cost-sharing than lower-income beneficiaries. The law requires the hawk-i board establish premium amounts based on a sliding-scale for eligible. For uninsured children under 19 not eligible for the public assistance expansion, the Iowa law mandates that an advisory council develop a plan by December 2008 to ensure their access to affordable, private coverage.

Including the Adults The reform law also paves the way to an even larger goal: providing all Iowans with access to coverage by 2013. Although the legislation does not detail how this goal will be met, it does charge two task forces with recommending affordable coverage options for uninsured adults by December 2008. A cost-sharing cap of 6 1/2 percent (as a percentage of family income) for such coverage is one guideline written into the law.

Representative Foege envisions that Iowa's plan for universal coverage among adults may not be unlike the coverage provided through Iowa's SCHIP, which contracts with private insurance plans.

"It's not set exactly how we are going to [cover all adults], but one possibility is making available a product for low-income people to buy to which the employer and employee could contribute, with maybe a small subsidy from the state," she said. "This is similar to what we do with the hawk-i program. It is a private insurance product, off the shelf, and parents contribute to it. We see the adult world becoming an expansion of what we do with the kids."

In addition to increasing health coverage, the law extends private insurance coverage for children on their parents' plan until they reach 25 years of age, marry or move out of the state. Prior to the law, children were allowed to remain on their parents' plan if they were under the age of 18 or a full-time student. Private insurers also are barred from excluding or limiting coverage based on preexisting conditions when a consumer switches from a group plan to an individual plan.

Mandate Debate One of the most contentious issues that lawmakers faced was whether or not to include a coverage mandate. According to Representative Foege, "The biggest sticking point [in the Legislature's debates] was whether or not to mandate health insurance for kids and, eventually, adults. A mandate, however, was not politically doable."

The state opted instead for a voluntary effort, including provisions for aggressive outreach to promote children's coverage. The law requires that, beginning with tax returns for the 2008 tax year, taxpayers will be given the opportunity to note on their returns whether or not their children are insured. If a taxpayer indicates their child is uninsured and the family's income suggests the child might be eligible for a medical assistance program, the state will notify the family of the child's eligibility for selected programs. Iowa lawmakers borrowed this idea from the state of Maryland. In May 2008, Maryland enacted a law (H.B. 1391) that requires taxpayers to note the insurance status of their children; the state will follow up with materials on the state's SCHIP, if the family appears to be eligible.

The Iowa law's enactment comes on the heels of a January 2008 report from a state legislative commission that recommended ways to reach universal coverage. H.F. 2539 serves as an important first step toward achieving the commission's goals.

STATE NEWS

MORE CHURCHES START PAYING FOR HEALTH-CARE SERVICES, LEAVING STATES TO CONFRONT THE QUESTION: ARE THESE GROUPS INSURERS?

Matthew Gever

Faith-based groups have long been active in health-care delivery, most visibly through religion-based hospitals and running community clinics. In recent years, religious groups have expanded their forays into the health-care arena, and some are now looking for ways to set up formal, quasi- insurance organizations, funded by parish members, to help other parishioners pay their medical bills.

"I absolutely think it’s the wave of the future," said Representative Joe Armstrong of Tennessee. This is especially the case as more congregations combine into large mega-churches that serve thousands of parishioners. "As they grow larger they will be looking to provide some level of care to fill a gap for people who aren’t insured," said Rep. Armstrong.

The rise of such organizations raises multiple important questions for states: should these groups be regulated like insurance companies, e.g., should they be required to cover all medically necessary procedures and establish sufficient reserves to ensure that all members who have had procedures have their bills paid? Or, because they are funded by voluntary donations from church members and because they do not formally enroll members, should they be excluded from state regulation as insurance companies?

This question has made its way to the floor in the Sunshine State. Florida lawmakers recently passed Governor Charlie Crist's "Cover Florida Health Access Act," (SB 2534) a comprehensive health reform plan described in a previous SHN article. Inserted into the bill was an amendment that would exempt faith-based health-care programs from oversight by the state's Office of Insurance Regulation if the group qualifies under federal guidelines as a non-profit religious organization.

"We set up a new category in our statutes that says if you're a religious organization that pools your interest and pools your money together then the state will leave you alone," said Representative Aaron Bean.

The amendment allows faith-based groups to establish rules for behavior among its participants, stipulating that the group must make clear in writing that it is not an insurance company. The groups' members vote on what qualifies for membership and payment while a board of directors oversees administration.

Groups such as Medi-Share, a Christian-based health program pools money and shares medical costs among its members, who must also be active in a church. Members who want to participate send monthly dues to the company, which then creates an account for each family. When a family needs a bill paid, the company moves the money around between accounts, what it calls "sharing" of medical bills, while the company makes no promise of bills being paid, which it says separates this practice form traditional insurance. Monthly dues range from $53 up to $570, depending on a persons age and family status as well as their chosen level of "Initial Member Responsibility," which is what the patient has to pay out of pocket before receiving assistance from Medi-Share. These range from $250 per incident up to $10,000. So if a doctor bill or a prescription costs less than this amount, the patient is entirely responsible for the cost. However, after the IMR, the patient is not responsible for any of the bill. According to the group's website, they have negotiated rates with a network of about 750,000 providers across the country. Use of other providers would result in the patient receiving less shared money.

"Technically it is not insurance because it's not a risk-based product," said Representative Bean. Others beg to differ. In Montana, the District Court ruled in 2007 that Medi-Share is in fact insurance, since the group uses health histories and actuarial principles to determine eligibility and rate structures. Courts in Kentucky ruled differently, saying the state's insurance code does not apply to religious groups.

Medi-Share will help pay for basic services such as physician visits, hospitalization, testing and some prescriptions. Not included is payment for treatment of any pre-existing conditions or procedures such as cosmetic surgery, abortion or fertility treatment. Additionally, participants have to agree to certain lifestyle restrictions such as no non-marital sex and abstention from alcohol, tobacco and other drugs. Anyone caught engaging in these behaviors is subject to expulsion from the program.

Legislators in Florida decided to add the amendment exempting Medi-Share and other groups because there was concern that OIR might shut them down or force them to conform to standards set for traditional insurance companies. Currently, about 7,000 Floridians are enrolled in Medi- Share and legislators feel that faith-based health care may be a way to help tackle the problem of the uninsured.

"From our standpoint we're looking for ways people can take care of themselves and if a group or individuals can find a way—anytime you can do it outside of government, more power to you," said Representative Bean.

Currently, ten states have exemptions that allow organizations such as Medi-Share to function, while four states have ruled that such religion-based organizations are in fact insurance and subject to state regulations.

"I think we need to establish federal guidelines for these health-care efforts, just like we did for HMOs, PPOs, whatever," said Representative Armstrong, hoping that. "They should be recognized as 501(c)3s by the IRS, and their administrative costs and what monies are actually going out to help their ministries should be monitored."

Regulation of faith-based health care often comes up in discussions of other social services such as child day-care and addiction treatment centers. Critics contend that faith-based groups are exempt from oversight of how they spend their money—something other large non-profits are required to report. Additionally, church plans are under no contractual obligation to pay for medical bills, potentially leaving a patient stuck with a high bill and no legal recourse. The non-faith-based groups also contend that their administrative costs are significantly higher because of their need to comply with state regulations. Supporters, however, contend that faith-based groups have been operating and providing services since the country's origins and presently provide a low-cost option for those who want to participate.

STATE NEWS

"SILVER ALERTS" SOUND THE ALARM WHEN CERTAIN SENIORS GO MISSING

Kelly Wilkicki

In February of 2008, 86-year-old Mary Zelter signed out of her Key Largo, Florida home for seniors to go food shopping. Less than a week later, her body was found by local fishermen.

As baby boomers age, more and more “Marys” will develop dementia, Alzheimer’s or other mental impairments. The Alzheimer’s Association estimates that currently, 5.1 million Americans suffer from that disease, the most prevalent form of dementia. Of individuals with some form of dementia, the Alzheimer’s Association estimates that six out of ten will wander at least once.

To protect seniors with mental impairments, a growing number of states are enacting laws that call for the development of “Silver Alert” or “Senior Alert” programs. These safety efforts are much like Amber Alert systems, which notify the public when law enforcement determines that a child has been abducted. The 2003 federal PROTECT Act directed the Department of Justice to issue minimum standards for Amber Alerts that states can adopt voluntarily. The Silver and Senior Alert systems are expected to cost very little because they build on the established Amber Alert systems.

So far, Colorado, Georgia, Illinois, Kentucky, Michigan, North Carolina, Oklahoma, Ohio, Texas and Virginia have implemented their own missing person notification systems for individuals with some form of mental impairments (see table below).

Ohio ratified its Senior Alert law earlier this year. “It is important that we have a consistent and systematic way to find our senior citizens when they are in need of being found,” said Ohio Senator John Carey.

The requirements vary from state to state, but generally the person must be over 65, have a mental impairment such as dementia or Alzheimer’s Disease and their disappearance must represent enough of a danger to their health or safety to warrant the activation of an Alert. (Please see the chart below to compare selected state legislation.)

The process of issuing a Silver Alert is fairly straightforward. In Texas, for example, family or legal guardians of a missing senior must provide to local law enforcement agencies proof of the individual's age, domicile in Texas, impaired mental condition and evidence that the individual’s disappearance poses a credible threat to the senior’s health. Once a local law enforcement agency requests it, the Department of Public Safety issues a Silver Alert. The alerts may be broadcast over radio and television using the National Weather Service’s Texas Warning system. The state Department of Transportation also may illuminate messages on automated highway signs and local law enforcement agencies conduct any activities that they deem appropriate.

Before the establishment of the Silver Alert system in North Carolina, officers were required to wait 24 hours before notifying the public about a missing, at-risk adult. The 2007 passage of a law establishing a Silver Alert system eliminated the waiting period. The first day a senior is missing is the most crucial because during that time, many individuals will sustain a serious injury or die.

Virginia’s Silver Alert system requires local authorities to act within two hours of the filing of a missing person report if that person meets the requirements of a Silver Alert. Previously, localities were unable to declare an alert, and had to wait for the State Police to make the announcement before commencing search activities themselves.

Promising Results Since January of this year, North Carolina has issued 17 Silver Alerts, and has found fifteen persons unharmed and only one deceased. Texas, whose system went live in the fall of 2007, has issued 31 Silver Alerts. Of these, 27 persons were found alive and three were deceased.

On the federal level, a measure to mandate a Silver Alert system in every jurisdiction is currently being drafted by Texas Representative Lloyd Doggett. Please visit the National Silver Haired Congress’ webpage for updates on the bill’s progress. Also, Representative Gus. M. Bilirakis (R-FL), introduced a measure to provide grants to states to establish or improve their Silver Alert systems. The Silver Alert Grant Program Act of 2008 would be administered by the Department of Justice.

Potential Objections New York Governor George Pataki vetoed one attempt to create such a system, saying it would make missing person alerts too common. Unlike Amber Alerts, which are for a specific population of abducted children, Silver Alerts cover a much broader population.

Despite having widespread support, not all states have implemented Silver or Senior Alerts. Michael Splaine, from the Alzheimer’s Association, is not worried by the slow uptake of these programs. The public was “galvanized at the wrong time in the legislative cycle,” said Splaine, who speculates that more programs will be established in the next legislative session. Also, he feels the states are being more “thoughtful” and are “going more cautiously” about developing their Silver Alert programs.

As of May 2008, Louisiana, New Jersey, Pennsylvania, New York and Rhode Island are considering Silver Alert legislation.

Silver Alert Laws

State Requirements • 65 or older • Domiciled in Texas • Have Alzheimer’s, dementia or another mental impairment • The disappearance poses a credible threat to the person's health and safety • Silver Alert must be requested with in 72 hours of the person's disappearance Texas • There is sufficient info for the public to help • 18 years old or older North • Suffering from dementia or other cognitive impairment Carolina • The person is believed to be facing potential harm • The individual be in danger, faces a credible threat • Age 65 or older • Mentally impaired • Reported missing Ohio • A temporary or permanent resident of the state • Domicile in Colorado • Has a verified developmental disability Colorado • Disappearance poses a credible threat to their safety • Has a cognitive impairment which prevents him/her from caring for himself without the assistance of a caregiver • 60 or older Virginia • The disappearance poses a threat to the health and safety of the senior • Disabled adult • Believed missing • In immediate danger or serious injury or death Georgia • Sufficient information exists to engage the public’s help

HIGHLIGHTS

HEALTH INFORMATION TECHNOLOGY

Google Provides PHR On May 19, the online web browser Google opened public access to Google Health, an online personal health record (PHR) service. Google Health allows users to store online their medical records and laboratory test results, as well as information about allergies, vaccinations and prescriptions. Users also can decide whether to share information in their PHRs with health-care providers. Google Health also allows users to search for medical information and use other online health care tools. The health-care industry considers electronic health records “crucial to reducing the cost of providing health care and eliminating medical errors,” but implementation of such technology has been painfully slow, in part because medical records must be standardized if they are to share data across different systems, reports the Boston Globe. It also remains to be seen how willing consumers will be to store sensitive personal medical information online. Patient advocates and privacy experts have “expressed concern that, despite password protection, sensitive health records stored online could be compromised,” the Globe reports. The Health Insurance Portability and Accountability Act (HIPAA) does not cover medical records placed on a third-party online service. Google, however, asserts that Google Health will have the highest level of security and that the company will share information in PHRs only at the request of users.

MENTAL HEALTH

Monitoring Traumatic Brain Injury The Maine Army National Guard has begun testing its members for brain injuries sustained during the war. The National Guard is collaborating with the Dartmouth Medical School to give computerized cognition tests to Guard members before they go to Iraq and Afghanistan and upon their return. The tests evaluate memory, recognition and attention span, among other things. Concussions are common among soldiers—the force of explosives can rattle the brain against the skull causing injury. Many veterans, however, are not evaluated for concussions and are likely not to report symptoms such as dizziness, blurred vision and memory loss. Currently, the Veterans Affairs Hospital in Togus, Maine is treating 62 Iraq and Afghanistan veterans for traumatic brain injuries, but the actual number of those with head injuries is thought to be much higher, according to the Bangor News.

PUBLIC HEALTH

Treating Autistic Adults Pennsylvania has become the first state to receive federal approval to spend Medicaid dollars on services for adults with autism, the Philadelphia Inquirer reports. Previously, Medicaid only allowed spending on services for autistic children up to age 21. The Keystone State will now spend $20 million a year on home and community based services for adults with the disorder, including respite aid for relatives who care for autistic adults and crisis intervention. The state expects about 200 adults to be served under this waiver, and hopes that the additional funding will help these individuals avoid institutionalization and lead more independent lives. This waiver was one of a series of recommendations put out by a 2004 statewide task force charged with examining ways to improve Pennsylvania's delivery of autism services.

GRAPHICALLY SPEAKING

HSAs MORE POPULAR, NEW STUDY SAYS

Matthew Gever

The number of Americans who receive health coverage from health savings accounts (HSAs) linked to high-deductible insurance plans has nearly doubled over the past two years, to 6.1 million Americans, according to a new report from America’s Health Insurance Plans. HSAs are intended to give consumers more control over their own health-care spending by allowing consumers to use tax- favored savings combined with a high-deductible health plan (HDHP) to pay for medical expenses.

The highest levels of growth were seen in the small group market. States with the highest percentage of HSA enrollees among their under 65 populations with private health insurance were Minnesota (9.2 percent), Louisiana (9.0 percent), District of Columbia (8.7 percent), Vermont (7.5 percent), Colorado (7.1 percent), Nebraska (6.4 percent), Connecticut (5.8 percent), Wisconsin (5.6 percent), Indiana (5.1 percent) and Iowa (5.0 percent).

States with the highest levels of HSA/HDHP enrollment were California (639,000), Florida (397,000), Illinois (384,000), Texas (358,000), Ohio (353,000), and Minnesota (325,000).

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RESEARCH & EDITORIAL STAFF Donna Folkemer, Forum Director Anna C. Spencer, Managing Editor Christina Kent, Editor Contributors: Allison Colker, Matthew Gever, Kory Mertz, Tara Lubin, Sarah Steverman, Kelly Wilkicki, Anna Wolke EDITORIAL INQUIRIES Anna C. Spencer, Managing Editor Tel: 202-624-5400 Fax: 202-737-1069 email: [email protected] State Health Notes is published biweekly (24 issues/yr.) by the FORUM FOR STATE HEALTH POLICY LEADERSHIP, an information and research center at the National Conference of State Legislatures in Washington, D.C. State Health Notes is funded through the generous support of the Robert Wood Johnson Foundation and the Henry J. Kaiser Family Foundation. For more information about State Health Notes, visit our Web site at: www.ncsl.org/shn or email us at [email protected] © Copyright 2008, State Health Notes