Author: Alicia Espinosa

Bridging the Digital Divide: Improving Access to Telemedicine

2020 has undoubtedly become the year for telemedicine. The COVID-19 pandemic has created unprecedented demand for virtual visits to support the continued need for timely, safe care while avoiding in-person contact. By offering many ambulatory care services, telemedicine protects both patients and healthcare providers by reducing possible exposure to COVID-19. Federal policymakers temporarily relaxed regulations that impede telemedicine utilization and expanded Medicare coverage of remote appointments to encourage this shift, which is so popular among patients and providers that the technology changes may become permanent. Yet, despite these efforts, some patients continue to face barriers to telemedicine due to disparities in digital access and “unread[iness]” to use the requisite technology. As policymakers consider permanent use of telemedicine, they must address these barriers to ensure that those with much to gain from virtual care are not left behind.

            The amended rules implemented by policymakers made telemedicine visits easier to obtain, but also assumed that individuals have access to technology that enables home video visits. According to an August study of Medicare beneficiaries, 26.3% of beneficiaries (approximately fifteen million people) had neither a home computer with a high-speed internet connection nor a smartphone with a wireless plan, making telemedicine video visits unlikely for those individuals. Furthermore, this technology gap disproportionally impacts low-income individuals, persons eighty-five years or older, and people of color—all of whom form a vulnerable population in terms of their health and economic characteristics. The ability of individuals in these groups to access care was already a concern pre-COVID, and the shift to a virtual system may widen existing disparities in access to care. One solution from a study authored by Health Policy Researchers at the University of Pittsburgh and Harvard Medical School, proposed to expand the Federal Communications Commission’s Lifeline program, which provides phone or internet service at a reduced-cost. Lowering the cost of virtual care, however, will not be enough. As telemedicine utilization rises, the issues contributing to the technology gap must be addressed.

            Even if the technology gap was mitigated, there are additional barriers that may prevent a person from engaging with telemedicine. The ability of some individuals to use telemedicine enabling technology prevents many people from accessing virtual care. To have a successful video visit, individuals need to know how to get online, use audiovisual equipment, and communicate without in-person social cues. A study conducted by medical researchers affiliated with the University of California, San Francisco indicated that, of Medicare beneficiaries age sixty-five and older, 38% of these individuals were “unready” to have video visits, largely stemming from inexperience with technology, and 20% were “unready” due to difficulty hearing, difficulty communicating, or dementia. Similarly, this accessibility gap disproportionately impacts people of color, low-income individuals, and persons eighty-five years or older.

Live closed captioning during virtual visits and digital literacy programs during may help make telemedicine more accessible. Recognizing the need for accommodations in virtual visits is crucial to safeguarding equity in the telemedicine boom. Telemedicine will likely become an increasingly important aspect of health care delivery as the COVID-19 pandemic continues. By developing policies that recognize and bridge the digital divide, policymakers would ensure that the virtual migration does not worsen existing disparities and inequity in health care and improve access to telemedicine.

Here We Go Again: The Return of Medicaid Block Grants

            Last month, the
Trump Administration unveiled a new demonstration program that has the
potential to dramatically overhaul the way Medicaid operates.  Currently, Medicaid is designed as a federal-state partnership in which the federal government matches the
money a state spends to cover its Medicaid population. The new program, Healthy
Adult Opportunity (HAO), would provide a route for states to receive a capped
amount of federal dollars (i.e., a block grant) in exchange for fewer
restrictions on determining who qualifies and what services are available to
them. Seema Verma, the Administrator of the Centers for Medicare and Medicaid
Services (CMS), celebrated this plan as an innovative approach to ensure the
long-term financial sustainability of Medicaid. While Medicaid’s financial
maintenance is an ever-present concern, HAO may reduce access to important healthcare
services, create greater financial risk for states, and present significant
legal barriers.

            Changing Medicaid’s financing scheme
creates greater financial risks for states that pursue HAO. Medicaid’s current
open-ended financing structure was designed
to broaden states’ ability to provide healthcare coverage to their low-income
residents by adjusting
federal funding depending on the state’s level of need. For example, if a
recession hits and Medicaid enrollment grows, federal funding would increase to
cover most of the additional costs. However, states adopting the new approach
must accept responsibility for costs higher than the caps. This change would shift financial risk to states, with federal funding cuts likely to occur
when states have the least ability to accommodate them— such as during
recessions, public health emergencies, and other instances when states must
balance high demand for coverage and budgetary strain. The risk of hitting the
funding caps would put pressure
on states to control spending by cutting coverage.

            States that adopt HAO will likely
face litigation. By offering funding through a capped fund scheme, the Trump
Administration claims expansive authority to overturn explicit statutory
requirements for Medicaid eligibility, cost sharing, and financing. The legal basis of HAO lies in the “expenditure authority” outlined
in section 1115 of the Social Security Act. This section authorizes federal
matching funds for expenditures not typically allowed under Medicaid, if these
expenditures are needed to implement an experimental project likely to assist
in promoting Medicaid’s objectives. However, two legal problems exist for this framework. First, the ability
of block grants to promote the objectives of Medicaid, the legal standard for the authorization of
these waivers, is unclear. The U.S. Court of Appeals for the D.C. Circuit recently affirmed that Medicaid’s main objective is to provide
health coverage to low-income people, but block grants would incentivize
coverage of fewer people. Second, the part of the Medicaid statute that governs
its open-ended financing structure is not listed
as a provision that is alterable through waiver.

            The heightened discretion offered by
the demonstration program may reduce access to services and impact millions of
people. To receive federal matching funds, states must provide core benefits (e.g.
hospital services) to mandatory populations (e.g. low-income pregnant women)
without imposing waitlists or enrollment caps. States may also receive matching
funds to cover “optional” benefits, such as prescription drugs. Conversely,
states that adopt HAO would receive broad, and in some instances unprecedented,
to change benefits. The demonstration project encourages states to include the
millions of low-income adults without children who obtained coverage through
the Affordable Care Act’s Medicaid expansion under capped funds, which would
likely negatively impact their ability to access health care. Moreover, states
would also gain the ability to deny coverage
for costly but necessary prescription drugs, including those for diabetes and
cardiovascular conditions. Finally, states may impose new out-of-pocket costs for physician visits and prescription drugs on
low-income enrollees. Cost sharing in Medicaid, even in the amount of a $1
copay, has been shown to deter people from accessing care.   

            The idea of capped funds to meet
Medicaid’s financing challenges is far from new. Policymakers have discussed
block grants for Medicaid since the Nixon Administration and as recently as the 2017
repeal-and-replace. In light of this history, the Trump Administration should
consider why prior administrations and congresses have chosen not to take up
this policy, as well as its potential to create financial risks, lead to
litigation, and reduce access to healthcare for millions
of low-income people.

Medicaid’s Power to Recoup: Estate Recovery and Long-Term Care

Financing long-term services and supports (LTSS) presents a
concern to older adults, lawmakers, and society at large. LTSS refers to those
services that meet a person’s routine health and personal care needs when he no
longer can perform these tasks on his own, often due to age or disability.
Affording LTSS is a challenge, as few people have the necessary financial
resources to meet its high costs, and many must eventually turn to Medicaid for
help. Medicaid is the largest payer of LTSS, covering 43 percent of national
LTSS spending in 2013 (Nguyen). Concerns arose over the
sustainability of Medicaid’s role in financing LTSS in anticipation of an aging
baby boomer population that will need LTSS. One solution intended to ameliorate
LTSS financing is the Medicaid Estate Recovery Program (MERP), which requires
states to recover payments from individual estates for long-term care services (Estate Recovery). However,
this program which is characterized by Rachel Corbett as “Medicaid’s Dark Secret,”
tends to bring more distress than actual revenue.

MERP intends to control LTSS costs by providing a way for
states to recoup the money spent on a recipient’s care. Since the beginning of
the Medicaid program in 1965, states have had the option to recover from the
estates of deceased beneficiaries over age 65 when they received benefits (MACPAC).            However, the highly billed savings
of estate recovery have yet to materialize.

In 2005, the AARP Public Policy Institute published a study analyzing the first decade of
mandatory estate recovery. The study found that Massachusetts collected an
average of $16,442 per estate in 2003; offsetting a little more than one
percent of its LTSS costs in total. That one percent made its efforts among the
most effective in the nation. In contrast, the average amount recovered from an
estate in Kentucky was $93, representing just 0.25 percent of its LTSS costs.
The total amount states recovered increased from $72 million in 1996 to $347
million in 2003. Nonetheless, estate recoveries accounted for less than one
percent of Medicaid’s total nursing home costs in 2003. Corbett notes that the
“overwhelming majority” of estates recovered under MERP are not worth the
hundreds of thousands of dollars needed to make an impact on Medicaid LTSS

thus, seems more punitive than economical. As described above, the average
amount recovered from an estate is far from the amount needed to reimburse the
billions of dollars spent on LTSS. Financing LTSS presents one of the greatest
challenges our healthcare system will face in the upcoming years. While
Medicaid has met this need for now, its role as the primary LTSS payer is
unsustainable. MERP was billed as a solution to manage the strain LTSS puts on
state and federal budgets, but the program, with its slim returns and human
cost, is not the answer. A few states have already responded to these concerns
by scaling back their estate recovery programs (Corbett). More state lawmakers should
consider following their lead.