Pre-existing Conditions in West Virginia

West Virginians disproportionately suffer from higher rates of illness, disease and disability. As a result, West Virginians also have some of the nation’s highest rates of pre-existing conditions. These are health conditions which were diagnosed or treated by a provider prior to the purchase of insurance. They are also those conditions undiagnosed by a physician for which a “prudent” person would have sought care. Until the Affordable Care Act (ACA) established a series of consumer protections,1 individuals affected by pre-existing conditions were generally unable to purchase insurance on their own. However, recently these protections have come under threat by Congressional and legal action. This brief seeks to assess how West Virginians would be affected if these efforts are successful by providing estimates for the number of West Virginians affected by pre-existing conditions. Overall, it finds that 720,000 non-elderly West Virginians suffer from pre-existing conditions that would make it hard if not impossible to obtain health insurance subject to medical underwriting

Making Medicaid Work in the Mountain State? An Assessment of the Effect of Work Requirements for Medicaid Beneficiaries in West Virginia

West Virginia is one of the poorest states in the nation, and West Virginians face some of the highest rates of illness and disability. One of the few bright spots for the health of West Virginians have been government-funded programs like Medicaid and the Children’s Health Insurance Program (CHIP). The Affordable Care Act (ACA), including the expansion of Medicaid under Governor Tomblin in 2014, has brought health coverage and access to care to hundreds of thousands of West Virginians. Today, about a third of West Virginians rely on Medicaid, and the program has become the backbone of the state’s health infrastructure. Yet various efforts to transform the Medicaid program, including rolling back the expansion under the ACA or transforming the program into a block grant, pose major challenges to beneficiaries and the state. The most recent proposal, the implementation of work requirements for beneficiaries promoted by the Trump Administration, also falls into this category. Based on this analysis, work requirements would pose a significant challenge for beneficiaries, state government, and the broader health care system in West Virginia. Work requirements have been touted by proponents for a variety of reasons including as encouraging a “culture of work,” prioritizing scarce government resources, providing a way out of poverty for beneficiaries, and undoing the disincentives inherent in public assistance programs. Based on these rationales, work requirements have been implemented in a variety of public assistance programs such as Temporary Assistance for Needy Families (TANF) program, the Supplemental Nutrition Assistance Program (SNAP), and some Section 8 Housing Choice Vouchers or rent subsidies programs. While proponents of work requirements have hailed these developments as vindication, more deliberate analyses raise questions about the overall effects of the reforms. Particularly, assessments of the long-term effects on beneficiaries and their families raise cause for concern. A number of challenges are inherent to establishing work requirements in the Medicaid program. These challenges make their implementation in an effective, efficient, and equitable manner a dauting task. These include: defining covered populations and exemptions defining work and community engagement developing infrastructure and bureaucratic capacity establishing reporting requirements defining sanctions and loss of coverage developing work supports and work incentives protecting beneficiaries and populations with vulnerabilities addressing cumulative challenges of out-of-pocket costs and health behavior incentives reducing effects on the larger health care system and other support systems accounting for other efforts to curtail public assistance Not surprisingly, most states seeking work requirements for their Medicaid program have only paid limited attention to these tasks. Great care must be taken by policymakers to avoid unintended consequences and inequities. Applying other states’ work requirements to the West Virginia context illustrate the potentially wide-reaching consequences for the state. Based on the U.S. Census Bureau’s 2016 American Community Survey (ACS) this analyses finds that a Kentucky-style work requirement, i.e. a work requirement applicable to the entire Medicaid population from ages 19 to 65, with certain exemptions for the disabled, students, caregivers of children or people with disabilities, would affect more than 200,000 West Virginians. Of these, 70,000 would be exempt, 36,000 are working and in compliance with the requirements, 17,000 are working but not in compliance with the requirements, and 78,000 are neither working nor in compliance with the requirements. Based on experience in other public assistance programs and the implementation of work requirements in Arkansas, coverage losses for non-exempt individuals alone could range from 66,000 to 112,000 West Virginians under a Kentucky-style approach. Alternative scenarios developed based on different childcare exemptions and work efforts required estimate coverage losses as high as 144,000 for non-exempt individuals. A number of barriers would make it particularly challenging for West Virginia’s beneficiaries to comply with work requirements. These includes limited educational attainment, health limitations, and limited access to transportation, phone, and internet. Moreover, most jobs obtainable by beneficiaries generally do not offer health benefits. High level of unemployment, labor surpluses, and high rates of persistent poverty point to the often limited demand for labor across the state. State government would also face significant financial exposure including costly IT upgrades, as well as the need to significantly augmented its administrative capacity to establish and implement the program. Finally, a reduction in the influx of federal Medicaid funding and ensuing coverage losses would pose tremendous challenges for health care providers, particularly those in the state’s most rural areas. Payment reductions would leave a deep mark on the state’s economy. Taking away medical coverage runs contrary to the goal of alleviating poverty and transitioning Medicaid beneficiaries into stable work environments. An expert consensus has emerged that universally emphasizes the strong positive effects that sustained health coverage has in supporting the work efforts of beneficiaries. Perhaps most concerning, a work requirement may cause significant harm to populations with vulnerabilities, even if they are technically exempted from them. Several other options exist, however. Strengthening the state insurance market by implementing a state-based individual mandate, establishing a reinsurance program, and restricting short-term, limited duration health plans would reduce premiums and increase coverage, as would an expansion of the Children’s Health Insurance Program and a dedicated outreach and enrollment campaign during open enrollment for the Affordable Care Act’s marketplace. Efforts to create healthier environments and lifestyles including higher tobacco and soda taxes and access to clean air and water are equally crucial, as are efforts to combat the rampant opioid epidemic

Quality Regulation? Access to High-Quality Specialists for Medicare Advantage Beneficiaries in California

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are concerns for those in micropolitan and rural areas, and even those in standard metropolitan areas, at times. Crucially, the connection between provider quality and networks can only be fully understood when connected to assessments of provider access. These findings also raise questions about how we think about provider networks and the adequacy of current approaches to network regulation

The lobbying you have never heard of: targeting the US President’s Office of Information and Regulatory Affairs

Lobbying has become a pervasive part of American politics with hundreds of organizations lobbying bills across thousands of issues. But, write Simon F. Haeder and Susan Webb Yackee, legislative lobbying is only half the story. In new research, they look at the lobbying of federal rulemaking agencies, such as the President’s Office of Information and Regulatory Affairs (OIRA). They find that despite a lack of media coverage, intense lobbying of OIRA occurs, as evidenced by the often substantive changes in OIRA’s final rules compared to the draft rules submitted for review

Despite Democrats’ takeover of the House, don’t expect Republicans to give up on undoing Obamacare

In the lead up to last week’s midterm elections, polls consistently showed that healthcare was on the forefront of many Americans’ minds. With the Democratic Party now in control of the US House of Representatives, Republican efforts to repeal President Obama’s signature healthcare reform, Obamacare, are likely to be significantly curtailed. But that doesn’t mean they will end completely, argue Simon F. Haeder and Philip Rocco. Drawing on evidence from their research on previous Republican actions to repeal Obamacare, they write that the influence of activists within their party means that the GOP are likely to continue their efforts to impede the full operation of the Affordable Care Act at the state level, through the courts, and via executive actions

While Congress sits on its hands, presidents are making policy by regulation

Despite what most of the public may think, the vast majority of policymaking by the federal government comes in the form of rules and regulations rather than through new laws. Using the 2010 Affordable Care Act as a case study, Simon F. Haeder and Susan Webb Yackee write that the move from law-based to regulatory policymaking has given Democratic and Republican presidents alike unprecedented powers that often do not need to take into account the views of Congress

Americans are divided on Medicaid work requirements, but it depends on recipients’ circumstances

This week the Biden administration requested a halt to a Trump-era Supreme Court challenge to state Medicaid work requirements. But how do Americans feel about work requirements for Medicaid recipients? In new research, Simon F. Haeder, Steven Sylvester and Timothy H. Callaghan find that while Americans are split in their support or opposition to Medicaid work requirements, public opinion is more nuanced when the public is asked who should be exempted from these requirements

When US presidents push for regulatory reform, liberal agency rules may be first in the firing line

One of the concrete achievements of the Trump administration in the last 18 months has been the rapid removal of a great deal of existing regulation. But what kinds of regulations tend to be recommended for modification or removal? Simon F. Haeder and Susan Webb Yackee have studied the role of the Office of Information and Regulatory Affairs or OIRA in government rulemaking and find that OIRA frequently recommends changes to rules proposed by agencies which tend to lean to the left politically, such as the Environmental Protection Agency. As Trump moves to expand OIRA’s powers, they warn that this may have significant implications for policy outcomes felt across the United States for the years to come

How Intense Policy Demanders Shape Postreform Politics: Evidence from the Affordable Care Act

The implementation of the Affordable Care Act (ACA) has been a politically volatile process. The ACA\u27s institutional design and delayed feedback effects created a window of opportunity for its partisan opponents to launch challenges at both the federal and state level. Yet as recent research suggests, postreform politics depends on more than policy feedback alone; rather, it is shaped by the partisan and interest-group environment. We argue that “intense policy demanders” played an important role in defining the policy alternatives that comprised congressional Republicans\u27 efforts to repeal and replace the ACA. To test this argument, we drew on an original data set of bill introductions in the House of Representatives between 2011 and 2016. Our analysis suggests that business contributions and political ideology affected the likelihood that House Republicans would introduce measures repealing significant portions of the ACA. A secondary analysis shows that intense policy demanders also shaped the vote on House Republicans\u27 initial ACA replacement plan. These findings highlight the role intense policy demanders can play in shaping the postreform political agenda

Quality Regulation? Access to High-Quality Specialists for Medicare Advantage Beneficiaries in California

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are concerns for those in micropolitan and rural areas, and even those in standard metropolitan areas, at times. Crucially, the connection between provider quality and networks can only be fully understood when connected to assessments of provider access. These findings also raise questions about how we think about provider networks and the adequacy of current approaches to network regulation