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MGH Community News |
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MGH Community News |
| June 2013 | Volume 17• Issue 6 |
Highlights
Sections Social Service staff may direct resource questions to the Community Resource Center, Lindsey Streahle, x6-8182. Questions, comments about the newsletter? Contact Ellen Forman, x6-5807. |
Supreme Court Overturns DOMA Section: How It Will Affect Same-Sex Married Couples The Supreme Court’s historic ruling this week that part of the 1996 Defense of Marriage Act (DOMA) is unconstitutional paves the way for married gay couples to receive more than a 1,000 federal benefits and protections their straight counterparts already have access to. The ruling applies to all married couples in Massachusetts, as well as the 11 other states and the District of Columbia where gay marriage is legal. The 1,138 federal benefits and protections already given to opposite-sex married couples will now apply to same-sex couples, and will affect the way businesses handle employee benefits, like healthcare and family leave. Scott Squillace, an estate planning lawyer at Squillace & Associates in the Back Bay, which has approximately 350 gay couples as clients, and Christopher Paul, an estate planning lawyer in New Hampshire’s McLane Law Firm, outlined some of the larger benefits gay married couples will now be able to receive: US Citizenship . Spouses who are citizens can now sponsor a visa for a non-citizen spouse and the foreign national can receive spousal preference for a path to citizenship. Social Security survivor benefits : If a spouse in the marriage dies, the surviving spouse can now collect the deceased spouse’s Social Security checks if that amount is higher than the one he or she was currently receiving. Federal health care protections: Same-sex married couples will now be eligible to receive COBRA benefits and spousal benefits in Medicare, cutting the cost of those health plans. Military benefits: Though the US military has repealed “Don’t Ask, Don’t Tell,” and promised to give 20 benefits to same-sex couples as early as August, all benefits to opposite-sex military spouses will now apply to same-sex spouses as well. Additionally, spouses of deceased veterans will be eligible to receive veterans’ benefits. Other benefits include spousal coverage under health care plans and housing allowances to cover gay married couples. Federal estate tax break: An unlimited marital deduction now applies on both the state and federal level, meaning that if one spouse wanted to leave all possessions and assets to the living spouse, he or she would be able to do so, without that amount being taxed. Previously, the federal estate tax was 40 percent on any estate over $5.25 million. Property sales : If one spouse sells land to another, capital gains taxes will not apply. Retirement plan rollover : A deceased spouse’s Individual Retirement Account can roll over into the survivor’s without being taxed first. Federal employee benefits : For federal employees, the government will recognize gay spouses, making them eligible for a variety of benefits such as healthcare coverage. Federal gay married employees can also participate in family medical leaves. |
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Some additional benefits include:
Married same-sex couples should revisit their estate and retirement plans in light of these new changes. Married Couples Living In States That Do Not Recognize Their Marriage Section 2 of the Defense of Marriage Act, which the court did not take up, does not require states to recognize gay marriages that took place in other states. It may be months or years before all the details are settled -- particularly the question of which benefits will be available to gay couples living in states that don’t recognize their marriages. Those lucky enough to live in states that recognize their marriages are upgraded to full state and federal benefits based on the DOMA ruling. Those who don’t live in such states remain in much the same situation as before. Q: How will IRS policies change? A: In a statement Thursday, IRS said it was reviewing the Supreme Court decision and "will move swiftly to provide revised guidance in the near future." While the IRS generally has based its decisions about married couples on the couple's current state of residence, that policy isn't written into law and could be changed, says Brian Moulton, legal director for the Human Rights Campaign, a gay rights organization. So, the IRS could release new policies that would be more friendly to same-sex couples, particularly those living in states that don't recognize same-sex marriage. Q. Will spouses of federal employees be eligible for benefits, even if they live in states that don't recognize gay marriage? A. In all likelihood, yes, says Fred Sainz, a spokesman for the Human Rights Campaign. The Office of Personnel Management, which oversees federal workers, is likely to extend benefits in all states, not just the 13 states and the District of Columbia that currently recognize same-sex marriage. Q. Do all federal agencies use the same standard to determine benefits for married couples? A. No. Some federal agencies base decisions on the state in which a couple was married, while others consider the couple's current residence, says Moulton. While the IRS currently bases decisions on a person's current address, the Department of Defense bases its decisions on where a married couple lived at the time of the marriage. Some agencies will be able to change their policies, while others agencies' policies are determined by Congress. "The president has said that all legally married couples should be recognized by the federal government," Sainz says. "This is rapidly evolving." Q. So what happens to military couples who move around a lot? A. Because military personnel live all over the world, and relocate frequently, the Department of Defense bases its decisions on the place where a couple was married, Moulton says. So if a male soldier marries another man in the District of Columbia, which recognizes the marriage, the military will continue to recognize that marriage, even if the couple moves to a state such as North Carolina, which does not recognize it. After the Supreme Court decision, Secretary of Defense Chuck Hagel said the military will move forward to make benefits, such as health coverage, available to all military spouses. Q. Does the Department of Veterans Affairs use the same criteria? A. No. By law, the VA bases its coverage decisions on a person's current address, not where they were married, Moulton says. Congress would have to act to change this. So, it's not clear whether a same-sex spouse would be eligible for benefits if that couple lives in one of the 38 states that don't currently recognize gay marriage. Q. What about Social Security benefits? Q. What about Obamacare? Obamacare establishes state and federal exchanges so people can explore all of their health coverage options in one place. States that run their own exchange programs decide who qualifies as family members, but the court ruling means that now the 26 federally run exchanges "have no bar to recognizing and including same-sex spouses as protected family members," said Shannon Minter, legal director for the National Center for Lesbian Rights. Q. Could gay couples lose benefits due to the Supreme Court decision? A. In some cases. Eligibility for Medicaid, a federal health insurance program managed by individual states, is determined by household income, Moulton says. So, it's possible that some same-sex couples will now make too much money to qualify for Medicaid, after their combined incomes are considered. Adapted from/References and More Information:
Arbour Mental Health Clinics Cited Dozens of therapists who were unlicensed or improperly supervised routinely treated mentally ill patients at three clinics owned by a major provider of care to low-income people in Massachusetts, state records show. At an Arbour Health System clinic in Lawrence, state inspectors determined that all 23 therapists were not qualified to see patients on their own, yet were doing so without regular oversight by a licensed professional. Similar staffing violations were discovered at Arbour clinics in Malden and Fall River. The state Department of Public Health, which regulates community mental health centers, required Arbour last year to develop plans to fix the problems at the cited clinics. Among other steps, the company promised to hold regular supervisory meetings with therapists and improve monitoring by clinic directors. Dr. Madeleine Biondolillo, director of the department’s Bureau of Health Care Safety and Quality, said the pattern of deficiencies is concerning, but she is satisfied with Arbour’s promise to do better. “This is an organization that has broad reach,” she said. “It’s a very, very important service that they provide, and it has to be done according to the regulations.” State regulations allow unlicensed workers to see patients in community mental health clinics, which serve large numbers of people who are low income or have serious mental illness — but only if those workers are regularly supervised by licensed mental health professionals. The practice is meant to ensure access to affordable mental health providers and to provide experience to therapists applying for licensure. Unlicensed workers can also fill a need for caregivers who speak Spanish or another language. While investigating the Lawrence clinic, inspectors found that five more Arbour therapists who were not licensed to practice independently went without regular supervision at a clinic in Malden. The company later said that a supervisor had been working with several of those therapists but didn’t chronicle their meetings. The clinic had been cited previously, in 2008, for not keeping records of supervision. The suit, being considered by a federal judge, centers on the care that teenager Yarushka Rivera received at the Lawrence clinic. Nearly every Arbour caregiver who treated Rivera in the two years before she died lacked proper qualifications or professional supervision, according to court records. In 2007 and 2008, Rivera saw two counselors, neither of whom had any professional license. When her parents complained in early 2009, clinic director Edward Keohan suggested that she see Anna Fuchu, who described herself as a psychologist. After a brief evaluation, according to the court filing, Fuchu diagnosed Rivera as bipolar. Fuchu was not licensed as a psychologist in Massachusetts, despite representing herself as one on Facebook and elsewhere online. Last year she agreed to pay a penalty of $1,000 and promised the state Board of Registration of Psychologists not to use the title. In May 2009, Rivera’s school said she would need an evaluation by a psychiatrist. Fuchu suggested Rivera see Maribel Ortiz, a licensed nurse practitioner at the clinic, the court documents said. Ortiz prescribed an antiseizure medication. She had the authority to write prescriptions as long as she had proper supervision from a psychiatrist. Ortiz’s supervisor was a physician but not a board-certified psychiatrist, and she did not have the qualifications to supervise Ortiz, according to state records included in the court filings. The company later told the state that the supervisor was eligible for board certification and planned to take the required exam last fall. State inspectors also visited Arbour’s Fall River clinic last spring and found that 13 of 27 therapists had refused supervision by the clinic director but were permitted to continue treating patients. -See the full Boston Globe article ... MA Unemployment Insurance Switching to Direct Deposit or Debit Card Payments Exclusively The Massachusetts Department of Unemployment Assistance (DUA) is introducing the Massachusetts DUA Debit MasterCard®, which will replace checks as a way of receiving unemployment benefit payments. Claimants will receive benefit payments via the debit card unless they sign up for direct deposit to a checking or savings account. Checks will not longer be issued; the last check payments for existing claimants will be issued for the week ending June 22, 2013. New applicants will receive payment by check for the first payment only. Claimants who receive the debit card will need to follow the instructions to activate the card. Claimants can check their balance and transactions online, at an ATM, or by calling the Debit Card Customer Service Center toll-free any time. Additionally, one can sign up for text or email alerts that payment has been deposited (additional charges may apply). Most transactions are free when used with the DUA Debit Card. However, there is a fee for using ATMs outside the Bank of America and Allpoint networks of $0.85 for each transaction, plus any additional surcharge fees imposed by the ATM owner. Information about services with no fees and with fees at www.bankofamerica.com/duadebit. UI Online Unemployment Insurance (UI) is also adding a new web-based system to serve claimants and employers more efficiently. UI Online’s key benefits include allowing recipients to perform more transactions on their own, rather than having to wait to speak to a claims agent on the phone and to request weekly benefit payments or access account information more conveniently with expanded hours (between 5:00 a.m. and 10:00 p.m. daily.) UI Online will be available on July 1, 2013. Current claimants should have received a letter and pamphlet with instructions on how to activate their UI Online account and access the services. More Information:
-Cited in/Linked from: Updates from MassResources.org, June 25, 2013 (As of March 2015 website no longer operational). Sequester Cuts Taking Hard Toll on Head Start When the school year resumes this fall, at least 1,359 Massachusetts children — 259 more than earlier estimated — will probably not be in Head Start classrooms because of automatic across-the-board federal spending cuts. The cuts are the legacy of so-called sequestration in Washington. In other cost-cutting measures, some programs also plan to start the school year late, while others will no longer provide transportation for the preschoolers. Head Start is a federal grant program designed to give 3- and 4-year-olds from low-income families a jump start on their education by intervening at a time in their lives when academic disparities begin to emerge. Early Head Start, which is a component of Head Start, serves pregnant women, infants, and toddlers. Started in 1965 as part of the War on Poverty, Head Start aims to address the social, emotional, and academic needs of more than a million children in classrooms nationwide as well as aid their families. Students learn ABCs, numbers, and science basics, most notably, in one Jamaica Plain classroom, about caterpillars. In Boston, about 200, or about 10 percent, of the seats in Head Start classrooms will be empty next year because of the reduction in federal funds. In Massachusetts, Head Start and Early Head Start provides about 16,000 preschoolers — 2, 500 in Boston — with a full day of learning in classrooms, and dental, vision, and nutrition services at no cost to families whose annual household incomes fall within federal poverty guidelines. For a family of four, that’s $23,050 per year. Nationally, the sequester’s 5 percent cut from Head Start’s $8.1 billion budget means 70,000 slots for children must be eliminated in order to achieve the necessary savings, according to initial estimates from the White House. -See the full Boston Globe article... Samaritans Closes Framingham Office This month Samaritans Inc. announced it would consolidate all operations in Boston and lay off five employees, four of whom were based in Framingham. Roberta Hurtig, executive director of Samaritans Inc., said closing the Framingham office was a tough decision by the board of directors to free up funds for expanded services, including prevention programs and support services for those who have lost someone to suicide. Calls to the hotlines are being diverted to Boston. To officials at Samaritans, eliminating the brick-and-mortar presence makes financial sense in a tough economy. But to many of the 100 volunteers and the staff who oversaw them, the sudden move is an affront to the spirit of a group rooted in support and friendship. Some volunteers say they feel bitter about the way the closing was handled. Founded about three decades ago, Samaritans of Framingham operated independently before becoming part of Samaritans Inc. eight years ago. Alan Quarello, who was executive director of Samaritans of Framingham before its absorption by the Boston group, wrote a scathing letter accusing Hurtig of bad management and sent it to Governor Deval Patrick, state Senator Karen Spilka of Ashland, and state Representative Chris Walsh of Framingham. Quarello wrote that operating costs were low relative to the call volume, and he asked that the Legislature review the matter. “Funding that should have gone to continue services in MetroWest was used instead by Boston to rent expensive office space and new furniture and hire additional staff,” he wrote. Regarding Quarello’s comments about the Boston office space, Hurtig said the move about three years ago took the Samaritans to a smaller, less expensive space. -See the full Boston Globe article... Boston Police Issue Transgender Search Guidelines The Boston Police Department has issued antidiscrimination guidelines for police interactions with transgender individuals that offer them new protections during searches and bookings. The new policies were announced several months after the city settled a lawsuit filed by a transgender woman against officers who arrested her for refusing to leave a women’s bathroom at a Boston homeless shelter. Under the new policies, reached after lengthy negotiations between police and the Massachusetts Transgender Political Coalition. Under the new policy, transgender individuals cannot be subjected to additional invasive search or frisk procedures. Prisoners can request the gender of the officers conducting the search, and transgender prisoners are to be transported alone and held in a cell without other prisoners, whenever possible. Under the policy, police must also address transgender individuals by their adopted name and must use appropriate pronouns. Jesse Begenyi, interim director of the transgender coalition, said the policies, which were under discussion well before the lawsuit, should help reduce discrimination against transgender people who come into contact with police officers. Yet the city already had an ordinance saying people have the right to use restrooms based on their gender identity, she pointed out. “It shouldn’t have happened in the beginning and shouldn’t happen any more,” she said. The coalition hopes to work with State Police to adopt similar policies. -See the full Boston Globe article...
National Alliance on Mental Illness (NAMI) Family-to-Family Program The NAMI Family-to-Family Education Program is a free, 12-week course for family caregivers of individuals with severe mental illnesses. The course is taught by trained family members who cover:
- Adapted from: News from Margolis & Bloom, LLP - June 17, 2013, Margolis & Bloom, LLP, and the NAMI website. AARP Online Caregiver Resource Center The better prepared you are to care for a loved one, the more manageable the task will be. On the AARP website you will get tips and advice on how to successfully begin your caregiving journey. The site includes articles on a wide variety of topics including housing options, legal and financial matters, self-care and end-of-life care. There are also chats, discussion boards, blogs and more. AARP CareGiving Resource Center. -Cited in/linked from News from Margolis & Bloom, LLP - June 24, 2013, Margolis & Bloom, LLP. For Staff and Patients: the Public Service Loan Forgiveness Program (PSLF) In 2007, Congress created the Public Service Loan Forgiveness Program to encourage individuals to enter and continue to work full-time in public service jobs. Under this program, borrowers may qualify for forgiveness of the remaining balance due on their eligible federal (not private) student loans after they have made 120 payments on those loans under certain repayment plans while employed full time by certain public service employers. Qualifying Loans William D. Ford Federal Direct Loan (Direct Loan) Program loans are eligible for PSLF. Federal Family Education Loan (FFEL) Program and the Perkins Loan Program loans may be consolidated into a Direct Consolidation Loan to take advantage of PSLF. However, only payments made on the new Direct Consolidation Loan will count toward the 120-month payment requirement for PSLF. Payments made on FFEL or Perkins loans, even if they were made under a qualifying repayment plan, do not count as qualifying PSLF payments. Qualifying employment Qualifying employment is any (full-time) employment with a federal, state, or local government agency, entity, or organization or a non-profit organization that has been designated as tax-exempt by the Internal Revenue Service (IRS) under Section 501(c)(3) of the Internal Revenue Code (IRC). A private non-profit employer that is not a tax-exempt organization under Section 501(c)(3) of the IRC may be a qualifying public service organization if it provides certain specified public services. These services include emergency management, military service, public safety, or law enforcement services; public health services; public education or public library services; school library and other school-based services; public interest law services; early childhood education; public service for individuals with disabilities and the elderly. The organization must not be a labor union or a partisan political organization. More Information Public Service Loan Forgiveness, from Federal Student Aid, An Office of the U.S. Department of Education.
Commonwealth CHOICE Open Enrollment Commonwealth Choice is non-subsidized health insurance available to uninsured adult Massachusetts residents. The program allows individuals to buy individual insurance at a group rate and is available to those ineligible for other programs such as MassHealth and Commonwealth Care. In most cases, one can only buy Commonwealth Choice insurance during an open enrollment period. There are some exceptions – qualifying events which cause one to lose other insurance -in which one can buy at other times. Open enrollment periods also allow existing members to change plans. Commonwealth Choice will have two Open Enrollments in 2013: the state Open Enrollment from July 1 - August 15; and the national Open Enrollment from October 1, 2013 - March 31*, 2014. During these periods, you can change your health plan for any reason. The implementation of the federal Affordable Care Act in Massachusetts requires some changes in plans. Commonwealth Choice plans, including new plans, will end on March 31, 2014 . *To avoid a gap in coverage, members will have to shop for a new plan no later than March 15, 2014. More information: Shopping for a health plan today? What you need to know -Adapted from: http://www.massresources.org/commonwealth-choice.html (As of March 2015 website no longer operational.) Medicare Reminder- Home Care Coverage RequirementsMedicare will pay for home care if all four of the following are true:
If you have questions about billing issues for home health care you should contact 800-MEDICARE. Learn more about Medicare’s coverage of home care at www.medicareinteractive.org. - From :Medicare Watch, Volume 4, Issue 23, Medicare Rights Center, June 06, 2013.
MassHealth Reminder - Programs That Cover Care at Home There are now a number of MassHealth programs available to help cover the cost of home care. To be eligible for the programs, an individual over 65 generally needs to have limited assets and income (there are no asset limits for those under 65). Following is a brief overview of some of the programs available to care for an elder at home. Home and Community Based Frail Elder Waiver (“Waiver”) and Community Choices (“Choices”) The Waiver program is for individuals who are 65 and older or 60 and older and disabled and would be eligible for nursing home care. Both programs provide the following services: skilled nursing, home health aide, housekeeping, laundry, transportation, grocery shopping, meal delivery, and wander response system. Personal Care Attendant (“PCA”) This program allows the individual to hire her own care giver and provides a supplement of about $12 per hour for the number of hours approved by MassHealth. There is no age limit for this benefit, but the individual must be deemed to be “disabled” by either MassHealth or the Social Security Administration. In addition, the individual must require hands on assistance with at least two activities of daily living. Adult Foster Care (“AFC”) This program is designed to provide assistance to live-in care givers. If the applicant is living with her care giver, the care giver could be eligible for up to $18,000 of income each year. This is tax free because it is treated as a stipend. To qualify clinically, the applicant must require assistance with at least one activity of daily living. In some cases these programs can be combined. Those seeking more information or with eligibility questions may want to consult an elder law attorney who has experience with all of the programs available to determine if there are any benefits available to supplement the cost of the care. There are income and asset limits, but there are often ways to obtain eligibility if you exceed these limits. -See the full article from Margolis & Bloom...
State Likely to Start Fiscal Year with Interim Budget According to the State House News Service, the annual state budget for fiscal year 2014 (beginning on July 1, 2013) is unlikely to pass before July 1. Gov. Deval Patrick filed a $4 billion interim spending measure which was passed through the Legislature in one day that will keep the money flowing after July 1, assuming no budget will in place for the start of the fiscal year. House Investigators Fault Disability Rulings as Lax The Social Security Administration is approving disability benefits at strikingly high rates for people whose claims were rejected by field offices or state agencies, according to House investigators. Compounding the situation, the agency often fails to do required follow-up reviews months or years later to make sure people are still disabled. Social Security acknowledges a backlog of 1.3 million overdue follow-up reviews to make sure people still qualify for benefits. But agency officials blame budget cuts for the backlog, saying Congress has denied the funds needed to clear it. The House oversight subcommittee on entitlements was scheduled to hold the first of several hearings on the disability program this week. Most Social Security disability claims are initially processed through a network of local Social Security Administration field offices and state agencies, usually Disability Determination Services, and most are rejected. If your claim is rejected, you can ask the field office or state agency to reconsider. If your claim is rejected again, you can appeal to an administrative law judge employed by Social Security. The hearing process takes an average of a little more than a year, according to Social Security statistics. So far this budget year, the vast majority of judges have approved benefits in more than half the cases they’ve decided, even though they were reviewing applications that had typically been rejected twice by state agencies, according to Social Security data. -See the full Boston Globe article ... State Senate Drafts Welfare Overhaul Welfare applicants would have to prove they have sought employment before receiving cash benefits under a broad overhaul unveiled Monday by state Senate leaders, who said the public assistance program is in need of major improvements. The measure would prod welfare seekers to try to find jobs through a state-run program, rather than applying for public assistance as a first option. Currently, welfare recipients have to prove only that they looked for work within 60 days of getting cash assistance. The bill, which follows widespread reports of fraud and abuse, also attempts to curtail identity falsification, and would force state agencies to share data that could prevent people from taking advantage of the system. Under the bill, adult welfare recipients would be required to use electronic benefit transfer cards with their photograph on them, and would face new perjury penalties for fraudulent declarations of identity. Fraud on work participation forms would also trigger perjury penalties. Under the bill, the Department of Transitional Assistance and the Commonwealth Corporation would revive an effort to link enrollees with full-time employment. For their first year in a job, participants in the program would be provided with child care, and employers would receive a subsidy toward the cost of providing health insurance. Currently, pregnant welfare enrollees are exempt from a work requirement during the last four months of their pregnancies. The bill would scale the exemption back to the final month of pregnancy. Under current law, the value of a welfare recipient’s vehicle is calculated in his or her asset assessment. The Senate bill would exempt one vehicle per household from the asset calculation. According to the State House News Service, former Gov. Mitt Romney had ended an integral component of the state’s 1995 welfare to work reform. The new bill would recreate the "full employment program" to help place welfare recipients in full-time jobs to get them off public assistance. The former Republican governor was also responsible for ending the practice of requiring photo identification on electronic welfare benefit cards. We’ll be following the course of this debate. Stay tuned... -See the full Boston Globe article... -See the State House News Service Weekly Roundup posted 6/21/13... Health Law Led to $2.1 Billion in Consumer Savings A new report estimates that U.S. consumers who purchase their own health insurance saved $2.1 billion last year due to tougher rules in the federal healthcare law. The report by the nonpartisan Kaiser Family Foundation estimates that individual premiums would have been $1.9 billion higher in 2012 without the requirements in the federal Affordable Care Act. In addition, the nonprofit group said individual policyholders nationwide should receive $241 million in rebates this summer. Insurers must issue rebates to individuals and small businesses if they don't spend at least 80% of their annual premiums on medical care. -See the full LA Times article ... -Cited in/Linked from: HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, June 07, 2013. Medicare Trustees Report Improved Finances- Are Cuts Really Necessary? The 2013 Medicare Trustees Report was released this month. The trustees found that the Medicare Hospital Insurance (HI) Trust Fund is solvent through 2026 - two years later than reported last year. Also, the Trustees projected that the standard Part B premium, which is about $105 in 2013, will remain unchanged in 2014, keeping out-of-pocket costs for beneficiaries down. According to The Medicare Rights Center, the report confirms that Medicare is not in crisis. These findings reinforce that there is no justification for cutting benefits or shifting additional costs to older adults and people with disabilities, half of whom live on annual incomes of $22,500 or less. -Adapted from: Medicare Watch, Volume 4, Issue 23, The Medicare Rights Center, June 06, 2013. Report of the Massachusetts Commission on Unaccompanied Homeless Youth The Massachusetts Commission on Unaccompanied Homeless Youth was established in late 2012 under the direction of the Legislature and Governor for intensive investigation into the problem of unaccompanied youth homelessness in Massachusetts and to develop recommended interventions. This month the Commission its inaugural report and recommendations. The group’s initial recommendations include:
See also: State Targets Gap in Federal Health Care Coverage A congressional mistake that could cause nearly 4 million people to be ineligible for federal subsidies in President Obama’s health care law has prompted Massachusetts officials to launch a new effort to try to close the gap. As reported previously (Why Some Families Won't Qualify For Subsidized Coverage Under the ACA, MGH Community News, February 2013), under what has become known as a “glitch” in Obama’s health plan, eligibility for insurance subsidies will be based on how much it costs workers who buy an individual plan, not the far more expensive family plan. The glitch would affect uninsured spouses and an estimated 460,000 children of workers who cannot afford the family coverage offered through employers. Although that was not what lawmakers say they intended, partisan congressional gridlock has closed off efforts to fix the glitch before the ambitious overhaul aimed at universal coverage kicks in fully next year. So officials in Massachusetts, where the framework for the national law was first enacted, are stepping in, saying they want to fix the glitch to help those affected in the Bay State. Advocates say they hope Massachusetts’ efforts will focus new national attention on the problem. Governor Deval Patrick’s administration has proposed a pilot program to allow workers at small businesses who cannot afford family coverage under their employer-sponsored health plans to qualify for subsidies, offered through the state’s Medicaid program, starting in January 2014, said Glen Shor, secretary of the Executive Office for Administration and Finance and former chief of the state’s health insurance exchange program. The state sent a letter to federal officials last week asking permission for the expansion. The Massachusetts pilot program, which is estimated to cost $33 million and would be paid for with state and federal dollars, is still a proposal that is winding its way through the state budget process, Shor said. State officials could not say how many people in Massachusetts will be affected by the glitch. The Obama administration issued final regulations on who would be eligible for insurance subsidies earlier this year. It determined that the standard of eligibility would be based on whether people could afford to buy individual coverage under plans offered by their employers, not family coverage, which typically costs three times as much. Under the Affordable Care Act, those for whom employer-sponsored individual coverage costs more than 9.5 percent of their household income would receive a government subsidy to buy insurance through their state’s health exchange — an online insurance marketplace debuting in January 2014. But the law does not make allowances for people whose premiums for family coverage exceed 9.5 percent of household income — as a family policy could do — even though the federal Government Accountability Office had recommended last year that the administration consider basing the criteria for insurance subsidies on affordability of family coverage. -See the full Boston Globe article... Other States’ ACA Policies Exclude Some of the Poorest The refusal by about half the states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance under President Obama’s health care law even as many others with higher incomes receive federal subsidies to buy insurance. More than half of all people without health insurance live in states that are not planning to expand Medicaid. In states like Texas, Florida, Kansas, Alabama, Louisiana, Mississippi and Georgia, those who have incomes from the poverty level up to four times that amount ($11,490 to $45,960 a year for an individual) can get federal tax credits to subsidize the purchase of private health insurance. But many people below the poverty line will be unable to get tax credits, Medicaid or other help with health insurance. Sandy Praeger, the insurance commissioner of Kansas, said she would help consumers understand their options. She said, however, that many of “the poorest of the poor” would fall into a gap in which no assistance is available. The Kansas Medicaid program provides no coverage for able-bodied childless adults. And adults with dependent children are generally ineligible if their income exceeds 32 percent of the poverty level, Ms. Praeger said. In most cases, she said, adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) “will have no assistance.” They will see advertisements promoting new insurance options, but in most cases will not learn that they are ineligible until they apply. In approving the health care law in 2010, Congressional Democrats intended to expand Medicaid eligibility in every state. But the Supreme Court ruled last year that the expansion was an option for states, not a requirement. At least 25 states — mainly those with Republican governors or Republican-controlled legislatures — have balked at expanding the program, in part because of concerns about long-term costs. -See the full New York Times article... Federal Health Law Falls Short of Fair Pricing Huge list prices charged by hospitals are drawing increased attention, but a federal law meant to limit what the most financially vulnerable patients can be billed doesn’t seem to be making much difference. A provision in President Obama’s health care overhaul says most hospitals must charge uninsured patients no more than what people with health insurance are billed. The goal is to protect patients from medical bankruptcy, a problem that will not go away next year when Obama’s law expands coverage for millions. Because the Affordable Care Act doesn’t cover everyone, many people will remain uninsured. Critics say the law has several problems:
The Obama administration responds that fair pricing is the law of the land, and that hospitals are expected to comply even if the IRS has not finalized the rules. The agency has begun compliance reviews, a spokeswoman said. The American Hospital Association says it urges members to limit charges to the uninsured in line with the federal law. But neither the administration nor the industry has statistics on how many hospitals are doing so. -See the full Boston Globe article... Opinion: Is Health Insurance an Antidepressant? Over the past several years, a stream of new information has dealt blows to the ideas that having medical coverage makes people healthier and enables them to get the care they need when they get sick or injured, and that broader coverage could help control our national health care bill by encouraging regular doctor visits and preventive care that cuts down on expensive emergency treatment. Data from a pioneering Medicaid program in Oregon suggest that expanding health coverage hasn’t saved the state any money—in fact, it increased annual health care spending by about 35 percent. Even more surprising is that, after two years, having Medicaid has done little to improve people’s physical health. But the Oregon data have revealed a separate, intriguing upside to the experiment that has thus far gotten little attention. According to a paper published in the New England Journal of Medicine this past May, people with access to Medicaid were 30 percent less likely than their counterparts to screen positive for depression. “I was surprised initially,” said Jonathan Gruber, a health care economist at MIT who is considered one of the architects of the Affordable Care Act and is a coauthor of the NEJM paper. “I didn’t realize what a mental health toll being uninsured was taking on people... People who are uninsured live under constant daily stress. They’re worried about getting sick, and they’re worried about paying the bills if they get sick.” A 2009 study by a team that included Senator Elizabeth Warren found that more than half of all personal bankruptcies happen because of medical bills. In that light, health insurance can be seen as a financial instrument designed specifically to protect against such a crisis. The reaction from some quarters following the publication of the recent Oregon paper included Michael Cannon, the director of health policy studies at libertarian think tank the Cato Institute commenting that “The absence of physical-health improvements indicts the entire enterprise.” Similarly, the Bloomberg View columnist Megan McArdle, wrote “Given this result, what is the likelihood that Obamacare will have a positive impact on the average health of Americans? Every one of us, for or against, should be revising that probability downwards.” For Gruber, such responses reflected the widespread belief that mental health issues are not as serious, or worthy of attention, as diseases like cancer and diabetes. “We as a society just don’t care about mental health in the way we care about physical health,” Gruber said. There are good reasons to think it should be. For one thing, studies have shown that depression increases the risk of stroke, heart disease, and diabetes. For another, depression costs society a lot of money, just like other medical issues: According to one widely cited paper, the annual economic burden in the United States alone is on the order of tens of billions of dollars. Even more to the point, though, is the argument that making people happier—relieving their stress, making them less depressed, and better able to pursue their goals—is exactly what public policy is for. As MIT economist Amy Finkelstein, one of the principal investigators on the study put it, “There are lots of things we pay for as a society, from bridges to public housing to national security, which we don’t do to save money—we do them because we think they have some other benefits, and then we measure those benefits to try to decide if they’re worth the costs.” As data collection continues, the Oregon study may yet show that over the long term, having insurance does in fact make people physically healthier. But as the Affordable Care Act plays out the Oregon experiment on a much larger scale, we may need to broaden the conversation about what constitutes “well-being,” and consider what we, as members of society, owe one another. -See the full Boston Globe article ...
When Someone is no Longer Safe at Home In her regular “In Practice” column, Dr. Suzanne Koven, a primary care internist at Massachusetts General Hospital, shares some reflections on this difficult transition. I know, first hand, how hard it is on adult children of elderly parents who haven’t prepared meticulously. My brothers and I caught countless last-minute flights to Florida to deal with the medical emergencies that befell Mom so frequently in her last years. In my practice, I’ve urged many older patients to sell their homes, give up their cars, and accept more help when it becomes clear that they are no longer safe, or able to take adequate care of themselves. “Surrender some independence in order to gain a better quality of life,” is my usual pithy line. And yet, when I imagine giving up my own home, I find it hard to be so unsentimental. Have I been too casual in advising elderly people to leave home, or even to accept unwanted help at home? For some, loss of independence is a worse fate than falling. -See the full Boston Globe article ... Moral Injury in Veterans: Defining The Deep Pain PTSD Doesn't Capture An estimated 22 veterans kill themselves in the U.S. each day. And suicide among men and women on active duty hit a record high in 2012, exceeding deaths from combat. As veterans and researchers try to figure out why, there’s growing interest in a condition known as “moral injury,” or wounds to a veteran’s spirit or soul from events that “transgress deeply held moral beliefs and expectations.” Jonathan Shay, a psychiatrist at the Department of Veteran’s Affairs’ clinic in Boston, coined the phrase moral injury in the mid-1990s. He was looking for a way to describe damage to a veteran’s spirit or soul that PTSD didn’t capture. The Department of Defense is spending $1.5 million on research to study possible treatments for moral injury. “Shay started the ball rolling, using literature to raise the consciousness of care providers and families,” said Brett Litz, a clinical psychologist with the VA’s health care program in Boston and a professor at Boston University. Now, Litz and colleagues are attempting to build out the science. Studies of active duty soldiers and Marines are underway to determine for the first time how often moral injury occurs, what it looks like and how to treat it. At Camp Pendleton in California, Marines who suspect they have post-traumatic stress disorder, or PTSD, come in for therapy and are asked this question: What currently is the most distressing and haunting experience that you had in multiple deployments? Researchers use the question to get at a soldier’s “principle wound.” Litz says when you sort Marines’ responses to establish their main wound, only about one-third of Marines actually have PTSD or anxiety from a traumatic, often life threatening event. Another one-third focus on loss, often the death of a close friend. And the final one-third describe a moral injury. Litz says of these three groups, Marines with a moral injury appear most at risk for hurting themselves. “Self-harm might arise because you feel unforgivable and damned and you may feel at a very deep level that you deserve to suffer,” Litz said. “So how is someone going to behave if they feel that they deserve to suffer? They may abuse drugs, they may drive dangerously, some may not even care whether they live or die.... If you feel undeserving and unforgivable, you may take one step forward in your relationships and your workplace and then three steps back,” Litz said. “You may feel guilty if you feel good.” WBUR aired a special series this week: ‘Moral Injury’: An Invisible Wound Of War. Listen to or read the transcripts of the full series at: http://www.wbur.org/series/moral-injury Also see: An Illustrated Look At ‘Moral Injury’ Long Term Effect of Depression Care Management on Mortality in Older Adults A recent article published in The BMJ (British Medical Journal) , found that older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression. 1226 participants were identified between May 1999 and August 2001 in 20 primary care practices in New York City, Philadelphia, and Pittsburgh. For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). -See the full Medscape summary article ...
Phone Calls May Help Keep Suicide at Bay in Bipolar Disorder A small novel telephone-based intervention to help ease the transition from inpatient to outpatient after a suicide attempt is showing definite promise as an effective suicide prevention strategy for people with bipolar disorder. Dubbed the Coping Long-Term with Active Suicide Program for Bipolar Disorder, or CLASP-BD, the intervention was found to be feasible and acceptable to patients to reduce their risk for suicide in the 12 months following hospitalization for bipolar depression. "Suicide risk in bipolar disorder is extremely high, arguably the highest amongst all the psychiatric disorders," Lauren Weinstock, PhD, from Brown University, Providence, Rhode Island, told Medscape Medical News. "We feel, from a clinical perspective, that we really need to develop interventions that target suicide specifically if we are going to reduce this risk," Dr. Weinstock said here at the 10th International Conference on Bipolar Disorders (ICBD). Suicide Risk Forgotten After Hospital Discharge As she was developing CLASP, Dr. Weinstock said she discovered that once patients were discharged from the hospital, the fact that they remained at risk for suicide was forgotten. "We found this anecdotally, and it is actually quite alarming. After a suicide crisis, patients often go back to their community providers, and the providers may pay some attention to the suicide attempt immediately after the hospitalization, but in the months that follow, it doesn't come up again in treatment. But the fact is, we need to continue to pay close attention to suicide risk, which remains very high in the first 12 months after hospitalization." The CLASP-BD program consists of 3 individual therapy sessions while the patient is in hospital, as well as 1 family meeting, which can take place while the patient is in the hospital or shortly after discharge, followed by 13 telephone calls to both the patient and to a family member over a 6-month period once the patient has gone home. "This is not meant to be a replacement for community treatment but to be an adjunct to treatment that we can deliver to people as they are making the transition from inpatient to outpatient," Dr. Weinstock explained. "We review the factors that contributed to the hospitalization, what things may have influenced their suicidal ideation, and then we shift gears and talk with them about what is important to them, their values, and so on. The idea is to help motivate them and help bring their actions back in line with their values and goals." In this small pilot trial, Dr. Weinstock and her team recruited 21 patients with bipolar depression who were psychiatry inpatients hospitalized for attempted suicide or because they had a definite plan to commit suicide. After 6 months posthospitalization, there were significant differences in rates of suicide attempts between the 2 groups, rates of suicide behavior and suicidal rehospitalization between the 2 groups. -See the full Medscape summary article: Phone Calls May Help Keep Suicide at Bay in Bipolar Disorder. Medscape. Jun 18, 2013. |