Kaiser Health News

The federal government, which spends billions of dollars each year covering unintended pregnancies, is encouraging states to adopt policies that might boost the number of Medicaid enrollees who use long-acting, reversible contraceptives.

LARCs, as they are known, “possess a number of advantages,” Vikki Wachino, deputy administrator for the Centers for Medicare & Medicaid Services, wrote to state programs in a recent bulletin. “They are cost-effective, have high efficacy and continuation rates, require minimal maintenance, and are rated highest in patient satisfaction.”

And, Wachino stressed, “more can be done to increase this form of contraception.”

The federal push reflects the continuing concern over the nation’s rate of unintended pregnancies, which is one of the highest among developed countries. The costs are significant not only for the families involved but also for the federal and state governments. In 2010, the latest year for which data are available, the federal government spent $14.6 billion and states another $6.4 billion on unplanned pregnancies. (Southern states were especially affected. In Mississippi, public programs covered 82 percent of such pregnancies.)

LARCs are considered a key way to help reduce all of those numbers. They include intrauterine devices and under-the-skin hormonal implants that, once in place, provide nearly complete protection against pregnancy for three to 10 years. In contrast, birth control pills are about 90 percent effective and must be taken daily.

Under Medicaid, the state/federal health program for low-income people, states must cover family planning services for women and men without charge. Although they have considerable latitude in determining which services, they’ve generally included most methods of birth control, said Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and advocacy organization that focuses on reproductive and sexual health.

Yet overall adoption of long-acting contraceptives has been slow in state Medicaid programs. In 2012, about 11 percent of low-income beneficiaries used a LARC, similar to the percentage of U.S. women overall.

Access in programs can be hampered by policies related to how LARCs are paid for and how services are provided, the CMS bulletin noted. It highlighted how some states are making changes to expand LARC use.

For example, it often is more efficient for a woman who has just delivered a baby to have an IUD inserted while she’s still at the hospital rather than wait until a postpartum visit several weeks later. But providers generally receive a bundled payment for labor and delivery services under Medicaid — and that doesn’t include IUD insertion. A dozen states — Alabama, Colorado, Georgia, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Montana, New Mexico, New York and South Carolina, according to the CMS bulletin — have implemented policies that now reimburse providers separately for inserting an IUD or hormonal implant right after a woman gives birth.

Another hurdle is the high up-front cost of long-acting contraceptives. This can be addressed by increasing payment rates to doctors as an incentive for them buying and stocking the devices, the bulletin noted.

Some state programs require that Medicaid participants first try a different contraceptive method before moving to a LARC, a practice referred to as step therapy. Or they require a plan’s prior authorization, which can delay or even block women from getting that method. Both minimize use.

South Carolina, which in 2011 had the 12^th highest teen pregnancy rate in the country, became the first Medicaid program to change its policy to reimburse providers for placement of LARCs immediately after delivery. The state now encourages the use of LARCs in outpatient settings by allowing the devices to be ordered by a physician but billed directly to Medicaid. In addition, it has eliminated prior authorization and step therapy as requirements.

The Center for American Progress, a liberal think tank, published a study last week calling for the increased use of LARCs for Medicaid enrollees both right after delivery as well as following abortion. It’s just one of a growing number of advocates, starting two years ago with the Association of State and Territorial Health Officials and continuing with the National Institute for Children’s Health Quality.

“The research is clear, LARC is the most effective and, over time, the least expensive reversible contraceptive method,” the nonprofits NICHQ and the the National Academy for State Health Policy stated in an issues brief last month. “Unplanned pregnancies are both medically difficult, with higher rates of preterm birth and low-birth weight babies, and incredibly costly. Wider adoption of LARC is a significant opportunity for states to reduce unnecessary expenditures in Medicaid programs.”

A recently published rule for managed care organizations that run many Medicaid programs also addressed LARCs. It said states must offer enrollees a choice of contraceptive methods and can’t require prior authorization or step therapy, said Mara Gandal-Powers, counsel for health and reproductive rights at the National Women’s Law Center.

“The language reinforces women’s access to the birth control method of their choice,” she said.

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Feds Urge State Medicaid Programs To Encourage Long-Acting Contraceptives

It’s a predictable passage in life: Hit 50, get lots of birthday cards with old-age jokes, a mailbox full of AARP solicitations — and a colonoscopy.

But millions of Americans — about one-third of those in the recommended age range for colon cancer screening — haven’t been tested. Some avoid it because they are squeamish about the procedure, or worried about the rare, but potentially serious, complications that can occur during colonoscopies.

Now, an influential panel has added some new choices, aiming to get more Americans screened for colorectal cancer, which is the second leading cause of cancer death in the U.S.

Here are five things to know now:

1) Getting tested — in any of a variety of ways — is a good thing.

Following its review of all the available medical evidence, the U.S. Preventive Services Task Force — an independent blue-ribbon panel of medical experts — updated its colorectal cancer screening guidelines. The panel gave an A rating to screening all adults between ages 50 and 75 years at average risk of the disease, saying the benefits are “substantial.” People with a family history or other risk factors might want to start earlier — and those older than 75 should talk with their doctors about whether to continue screening.

Noting that not enough Americans are getting screened, the panel essentially said the best test is the one that patients will take: “The goal is to maximize the total number of persons who are screened because that will have the largest effect on reducing colorectal cancer deaths.”

2) Two less-invasive tests may qualify for free preventive screening.

The biggest change from prior guidelines is the panel’s inclusion of two more ways to screen for the disease, including virtual colonoscopies, like the one President Obama had in 2010. Also called computed tomography (CT) colonography, the test uses special X-ray machines to examine the colon. The panel also added a $650 home test called Cologuard, which checks stool for elevated levels of altered DNA that could indicate cancer. Those tests join several others that were part of the panel’s previous recommendations: the full colon exam called colonoscopy; sigmoidoscopy, which uses a lighted tube and camera to examine just the lower portion of the colon; and two other types of home stool tests, fecal occult-blood tests and fecal immunochemical tests. Because of the task force’s A rating for colon cancer preventive screening, these tests generally must be offered to insured patients without a copayment or deductible under the rules put in place by the Affordable Care Act.

3) Don’t expect all insurers to drop copays on the new tests right away.

While Medicare already covers Cologuard as a preventive screening tool, many private insurers don’t. Of people with private insurance who are in the target age range, about 1 in 4 currently has coverage for the test, said Kevin Conroy, president and CEO of Exact Sciences, which makes the test. “That’s going to change,” he said, “because health plans have told us that they will follow the task force’s guidelines.”

When it comes to virtual colonoscopies, some insurers — including Cigna — cover them, but Medicare doesn’t. In 2009, Medicare said there was insufficient medical evidence to determine whether such tests should be covered nationally.

Now Medicare will likely be asked by proponents of virtual colonoscopy to revisit that decision.

Under Obamacare, insurers have up to a year to incorporate A- or B-rated screening tests into their benefit packages without a copayment. But there is some ambiguity in this case because the screening itself — not the individual tests — was given the A rating. While many experts believe insurers must offer all the types of tests, that isn’t entirely clear. Insurers and patient advocate groups both say they will seek additional clarity from the Obama administration.

4) The task force didn’t pick favorites.

The panel did not rank the tests, noting a lack of head-to-head comparisons showing any one method has the most net benefit. All tests have pros and cons. For example, getting a colonoscopy every 10 years has the advantage that, if potentially cancerous polyps are detected, they can be removed during the procedure. But it also carries a small risk of harmful complications, such as anesthesia-related cardiac problems, bowel perforations or abdominal pain. Sigmoidoscopy at five-year intervals has a lower rate of complications, but can miss some cancers because it doesn’t reach the entire colon. Annual stool tests, which don’t themselves carry any risk, reduce colorectal cancer deaths, the panel noted. The newer FIT immunochemical stool tests are a bit better at spotting cancers than FOBT, which studies show can correctly identify cancers 62 percent to 79 percent of the time. Cologuard — recommended every one to three years — detects existing cancers 92 percent of the time, but has a higher false-positive rate than FIT. Virtual colonoscopies, which expose patients to X-ray radiation, spot existing cancers of 10 millimeters or larger 67 percent to 94 percent of the time. The exam can also lead to additional, sometimes unnecessary testing because it flags potential problems outside the colon 40 percent to 70 percent of the time, with only about 3 percent of those concerns ultimately needing some form of treatment, the panel noted.

5) You might still get hit with a copayment.

Although preventive screening is covered without copayments or deductibles, some patients still end up with a bill. Medicare, most notably, requires a 20 percent copay if a polyp is found during a screening colonoscopy and removed. That payment averages $272, although advocates say they have seen far higher bills. Most private insurers do not charge patients if a polyp is found during a preventive screening, following Obama administration clarifications on the topic.

Two bills in Congress aim to apply those same rules to Medicare.

Another way consumers can get hit with a copayment is if a stool test, sigmoidoscopy or other exam indicates cancer might exist. A colonoscopy is then performed and some insurers consider that test a diagnostic exam, rather than a preventive screening. The American Cancer Society Cancer Action Network says it has asked the administration to clarify what happens in such a case. “If a patient has a positive test, the next step is colonoscopy, and therefore should be covered without cost-sharing,” said Caroline Powers, director of federal relations with ACSCAN. “We’re trying to get more people screened.”

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente. Follow Julie Appleby on Twitter: @Julie_appleby.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.

References to the Affordable Care Act — sometimes called Obamacare — have been a regular feature of the current presidential campaign season.

For months, Republican candidates have pledged to repeal it, while Democrat Hillary Clinton wants to build on it and Democrat Bernie Sanders wants to replace it with a government-funded “Medicare for All” program.

But much of the policy discussion stops there. Yet the nation in the next few years faces many important decisions about health care — most of which have little to do with the controversial federal health law. Here are five issues candidates should be discussing, but largely are not:

1. Out-of-pocket spending: Millions more people — roughly 20 million, at last count — now have health insurance, thanks to the new coverage options created by the ACA. But most people are also paying more of their own medical bills than ever before. And they are noticing. A recent Gallup survey found health costs to be the top financial problem faced by adults in the United States, outpacing low wages and housing costs.

Employers, who still provide coverage to the majority of those with insurance, are also battling rising costs. They have been passing at least part of that along by raising workers’ share of costs — including premiums, deductibles and the portions of medical bills they must pay — far faster than wages have been rising.

Meanwhile, even in the most generous plans offered to those who buy their own coverage through the ACA’s marketplaces, the portion of health care costs borne by consumers has left many unable to afford care.

As insurers have shortened their lists of “in network” doctors and hospitals, another out-of-pocket spending problem is becoming more common: The “surprise medical bill.” Those are bills for services provided outside a patient’s insurance network that the patient did not know was out-of-network when he or she sought care.

Some of the candidates — notably Clinton and Sanders — have talked about the issue. But serious discussion about ways to ensure health care services remain broadly affordable have been overshadowed by the fight over the fate of the federal health law.

2. Drugs — more than prices: Rising drug prices at the pharmacy counter have also proved problematic for patients. And both Republican and Democratic candidates have discussed proposals to address the cost of prescription drugs.

But there is more involved in this issue than the prices paid by patients.

Drugmakers point out their industry is a risky one, and the big rewards on breakthrough drugs offset the losses for those that never make it to the pharmacy. But at what point does the cost to society for a drug, like new treatments for hepatitis C that tally more than $80,000 for a course of treatment, become prohibitive?

Meanwhile, scientists are rapidly approaching the point of being able to develop specific drugs for specific individuals, a trend known as “personalized medicine” or “precision medicine.” But even if everyone could be screened so that they would only get the expensive drugs that will help them specifically, how could those costs be spread over society as a whole?

And how fast should promising drugs be brought to market? Some decry the lengthy testing required for Food and Drug Administration approval. They say people are dying who could potentially be helped. But others are equally concerned that putting a drug on the market too soon poses risks to the public.

3. Long-term care: Every day, another 10,000 baby boomers turn 65 and qualify for Medicare. An estimated 70 percent of people who reach that threshold will need some sort of long-term care.

It’s not cheap. The annual cost of these services can range from approximately $46,000 for a home health aide to $80,000 or more for a bed in a nursing home.

Yet Medicare, the health program for the elderly and some disabled, does not pay for most long-term care services. Medicare has both nursing home and home care benefits, but they are temporary and limited to those with specific medical needs. Most people who need long-term care don’t need special medical interventions, just help with “activities of daily living.”

By contrast, Medicaid, the joint state-federal health program for people with low incomes, paid just over half of the nation’s estimated $310 billion tab for long-term care in 2013, the most recent year for which this information is available. But you either have to be very poor, or spend nearly all of your savings, in order to qualify.

Private insurance for long-term care exists, but it is expensive, and remains uncommon — paying for just 8 percent of the 2013 bill. And private insurance for long-term care has been getting more difficult to purchase as insurers pull back from the products because of rising costs as people, especially women, live longer.

4. Medicare: Speaking of seniors, Medicare, which provides health insurance to an estimated 55 million people — 46 million older than age 65 and another 9 million with disabilities, is also in a financial bind.

Medicare accounts for 14 percent of all federal spending, and that is expected to grow rapidly as those boomers reach their highest health-spending years. The program already accounts for one of every five dollars spent on health care in the U.S.

Interestingly, Medicare spending has slowed dramatically in recent years. That has prompted a lively debate among health policy experts: How much is the slowdown due to the deep recession that caused spending to fall in all sectors of the economy, and how much to other factors that could continue even with stronger economic growth?

The Obama administration contends that changing the way Medicare pays health care providers, as begun in the ACA, has helped put the program on more sustainable footing.

Many Republicans, however, led by House Speaker Paul Ryan, R-Wis., want to effectivelyprivatize Medicare — which would transfer the risk for cost increases from the government to private insurers.

But even smaller changes can kick up big political pushback from those who rely on Medicare for their livelihoods. A recent Obama administration proposal to change the way the program pays for expensive drugs administered in doctors’ offices or clinics has brought cries of complaint from both Democrats and Republicans.

5. Dental care: In 2007, a Maryland 12-year-old named Deamonte Driver died from a tooth infection that spread to his brain. That cast a harsh spotlight on the difficulty low-income Americans — even those with insurance through the Medicaid program — have getting dental care.

Yet research has shown repeatedly that care for the mouth and teeth is inextricably linked to the rest of the body. Oral problems have been linked to conditions as diverse as heart disease, diabetes and Alzheimer’s disease.

Lack of dental care is particularly significant for children. Dental problems are common in youngsters, and in addition to discomfort, lead to school absences and poorer academic performance.

Findings like that are one reason the federal health law made pediatric dental care an “essential benefit” for most insurance plans. But for complicated reasons, including the fact that dental insurance has traditionally been sold separately from other health coverage, many children insured under the law are not getting dental coverage.

Coverage for adults remains spotty as well. According to the Centers for Disease Control and Prevention, one in every three adults has untreated tooth decay. More than 100 million Americans do not have dental insurance, the government reports. And more than a third (38 percent) of adults aged 18-64 reported no dental visits in 2014.

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Five Health Issues Presidential Candidates Aren’t Talking About — But Should Be

News that a subsidiary of CareFirst BlueCross BlueShield will stop selling bronze-level health plans on the Virginia marketplace next year prompted speculation that it could signal a movement by insurers to drop that coverage level altogether.

The reality may be more complicated and interesting, some analysts said, based on a look at plan data.

Bronze plans provide the least generous coverage of the four metal tiers offered on the insurance marketplaces, paying 60 percent of benefits on average, compared with 70 percent for silver plans, which are far more popular.

During the 2016 open enrollment period, 23 percent of marketplace customers signed up for a bronze plan, compared with 68 percent who chose silver, 6 percent who picked gold and 2 percent who chose a platinum plan.

Next year, the CareFirst BCBS subsidiary Group Hospitalization and Medical Services will no longer offer bronze plans on the Virginia marketplace, and bronze plan members will be moved into silver plans, said a spokesperson for the insurer. The company will continue to offer bronze plans on other exchanges, however.

The decision spurred some health policy analysts and health law critics to question whether other insurers would follow suit. Part of that reasoning had to do with the health law’s risk adjustment provisions. In the program, individual and small group insurers that enroll sicker, generally costlier members receive payments from insurers that enroll healthier, less costly members. Since bronze plans may attract healthier people, insurers may stop selling them to avoid risk adjustment program payments, some argue.

Between 2015 and 2016, the number of bronze plans offered on the marketplaces increased less than 1 percent, while the number of silver plans grew by 2.9 percent, according to data from the Robert Wood Johnson Foundation.

It’s too soon to say whether CareFirst’s shift signals a trend in insurers pulling back from the bronze metal tier, said Katherine Hempstead, who leads RWJF’s work on health insurance coverage. But even if that happens, it’s unclear that the effect on consumers would be negative.

Bronze and silver plans may become more similar as time passes, Hempstead said.

Insurers have some wiggle room in designing plans. Although bronze plans must pay 60 percent of costs on average, they can range from 58 to 62 percent. Likewise, every silver plan doesn’t have to pay exactly 70 percent of costs on average; a plan can pay from 68 to 72 percent. Issuers can design plans that pay at the low or high end of these ranges and still meet the criteria for a bronze or silver plan.

An analysis of the premiums for bronze and silver plans in census regions across the country reveals that average prices for the two types of plans moved toward each other slightly between 2015 and 2016, Hempstead said. In addition, looking across all regions the highest-priced bronze plan was significantly more expensive than the cheapest silver plan in each region in 2016.

A recent analysis by the actuarial firm Milliman found that while people who purchased silver plans tended to get those with lower premiums, those turning to bronze plans chose the more expensive options. “Many issuers found it difficult to develop [bronze] plans that were palatable to consumers and in the bottom portion of the metallic level range,” the report concluded.

“It’s interesting if the industry standardizes itself,” Hempstead said, “and what if the most common plan becomes a sort of bronzy silver?”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.

Teenage girls are catching up to teenage boys in one way that does no one any good: lack of sex education, according to a recent report.

The proportion of teenage girls between the ages of 15 and 19 who were taught about birth control methods declined from 70 to 60 percent over two time periods, from 2006-2010 and 2011-2013, the analysis of federal data found. Meanwhile, the percentage of teenage boys in the same age group who were taught about birth control also declined, from 61 to 55 percent.

“Historically there’s been a disparity between men and women in the receipt of sex education,” said Isaac Maddow-Zimet, a coauthor of the study and a research associate at the Guttmacher Institute, a reproductive health research and advocacy group. “It’s now narrowing, but in the worst way.”

The study, which was published online in the Journal of Adolescent Health in March, analyzed responses during the two time periods from the Centers for Disease Control and Prevention’s National Survey for Family Growth, a continuous national household survey of women and men between the ages of 15 and 44.

In addition to questions about birth control methods, the study asked teens whether they had received formal instruction at their schools, churches, community centers or elsewhere about sexually transmitted diseases (STDs), how to say no to sex or how to prevent HIV/AIDS.

Overall, 43 percent of teenage girls and 57 percent of teenage boys said in the most recent time frame that they hadn’t received any information about birth control before they had sex for the first time.

The proportion of young women who said they had been taught about how to say no to sex declined from 89 to 82 percent over the two study periods. For young men, the proportion remained essentially unchanged, inching up to 84 from 82 percent.

There were slight declines in the proportions of young women and men who said they had been taught about STDs and HIV/AIDS, but the responses were above 85 percent during both study periods for both sexes.

Teens talked with their parents to varying degrees about birth control and STDs. However, 22 percent of young women and 30 percent of young men said they didn’t talk with their parents about any of the topics.

The study also notes that the decline in formal education about birth control occurred even though the federal government spending has increased for teen pregnancy prevention programs.

Despite the lack of formal teaching, teenage pregnancy rates have declined for more than two decades and are now at historic lows. Racial disparities remain, however, and few teens use highly effective long-acting contraceptives such as intrauterine devices or hormonal implants.

“Even though the teen pregnancy rate is declining, it might decline faster if teens were getting sex education,” Maddow-Zimet said.

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Even As Birth Rates Fall, Teens Say They Are Getting Less Sex Education

Administration officials moved Thursday to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expanding eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates “is critical to our goal of reducing recidivism and promoting the public health,” said Richard Frank, assistant secretary for planning for the Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

“It’s highly variable. Some states and jurisdictions are having a lot of success” enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. “Others of them have initiatives in place that aren’t reaching the kinds of numbers that are making a dent.”

The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 up to January 2015.

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS’ guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners’ names in the Medicaid computers while they’re locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is “providing encouragement and a nudge” to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. “They understand that this is a technology issue.”

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they’re fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, “if you have a fair amount of freedom of movement” in a halfway house, “you’re not considered an inmate” for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. “That will be very helpful for a lot of people who are trying to transition out of incarceration.”

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland’s Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

“That helps a lot” if people like him could get on Medicaid after they first leave prison, he said. “People can get the health care they need sooner. I’ve been out a week now and I still haven’t been able to see a doctor because I don’t have my card.”

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage “can mean the difference between life in the community and recidivism and even life and death,” Michael Botticelli, the White House’s director of national drug control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act’s Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far 31 states and the District of Columbia have expanded Medicaid under the law.

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HHS Acts To Help More Ex-Inmates Get Medicaid