Tens of millions of Americans go without needed dental care because they cannot find a dental provider, can’t afford care, lack dental insurance or are unaware of the importance of dental care. By the time they reach kindergarten, more than 40 percent of American children experience tooth decay. Painful dental problems affect children’s overall health and ability to focus in the classroom. Increasing numbers of adults are seeking care at emergency rooms for dental problems because they have nowhere else to go, creating a large unnecessary expense to the healthcare system. In a recent study of PHAN’s newly insured individuals, nearly half cited cost and 36% cited transportation as barriers to dental care. PHAN is advocating to advance practices that increase access to oral health services, education, and prevention – especially for our most vulnerable Pennsylvanians. PHAN believes we need to strengthen adult dental health benefits in our current Medicaid package.
Health care costs are continuing to rise. Without adequate protections in place for consumers costs can become barriers to care. In addition to rising premiums, consumers also face out-of-pocket costs including deductibles, co-pays and co-insurance.
PHAN advocates to protect consumers and strengthen polices at the state and federal level that relate to affordability and how rates are set in Pennsylvania. We believe that costs should not create barriers to care, that consumers should easily be able to understand which costs they are responsible for paying, and that there is transparency and consumer input in our rate setting process.
Community Health Choices
Community Health Choices is a new program for Pennsylvanians that will coordinate physical health care and long-term services and supports through Medicaid. Older individuals, persons with a physical disability, and persons who are eligible for both Medicaid and Medicare (dual eligible) are eligible for Community Health Choices.
Under Community Health Choices, managed care organizations will be responsible for coordinating the physical and support services of each consumer, ideally in the home or community setting. This program seeks to fix our current system, where information about services is often confusing, navigating from primary care to long-term services can be difficult, and insurance options for long-term care are limited and expensive.
When managed long-term services and supports (MLTSS) programs were enacted in other states, the outcomes were positive:
Pennsylvania will roll out the Community Health Choices program in three phases:
PHAN will be closely monitoring the implementation of Community Health Choices and reporting difficulties as they arise. Please contact us if you or someone you care about would like to share a story about Community Health Choices.
If your organization would like to learn more about Community Health Choices, please contact Erin Ninehouser at firstname.lastname@example.org or 412-863-1047.
We are committed to making sure Community Health Choices works for you!
If you go to an “in-network” hospital clinic or have a medical emergency, you have every reason to assume your care will be covered. But, often this is not the case. Every year, Pennsylvanians receive out of network services without their knowledge — and are stuck with the bill. They are left to fend for themselves in negotiations with their insurance plans when their doctor and their plan can’t agree on a fair price for the services.
“Surprise” medical bills can place a significant financial strain on families. Almost two-thirds of personal bankruptcies are related to medical debt. These bills hurt families, which is just not fair.
Pennsylvania can change this, but we need your help!!!
At PHAN, we believe that access to health care should not depend on what family you were born into. But 24,000 children in Pennsylvania go without necessary pediatric check-ups, dental exams, and medications they need to stay healthy. Because they are undocumented, these children are denied access to our state Children’s Health Insurance Program (CHIP).
The Dream Care Campaign is working to change 13 words in state law so that all Pennsylvania’s children, regardless of their immigration status, can receive quality health care.
Pennsylvania can provide CHIP coverage to these children – who make up less than 1% of all children in PA.– for approximately $15.4 million, less then 1/20th of 1% of the state budget. And over the last year, the federal government has provided more financial support for CHIP program costs, which means that Pennsylvania’s state costs have been reduced by $90 million. Providing health insurance for undocumented children saves money in the long run, too: The amount of money it takes to insure a child through CHIP is half the amount hospitals and the state currently cover in uncompensated care costs for each child.
Five states have already made undocumented children eligible for CHIP or Medicaid, and seven out of ten Americans believe undocumented children have a right to the same benefits as refugees: Medicaid or CHIP eligibility.
PHAN is part of the 40-member Dream Care Coalition, led by Public Citizens for Children and Youth. Click here to sign on to the Dream Care Campaign and work to fulfill Pennsylvania’s promise to cover all kids!
When consumers enroll in a health insurance plan, they gain access to a network of medical providers. Insurance companies contract with a range of providers, including both primary care and specialty physicians, to deliver health care services included within the plan’s benefit package. This network of providers must be adequate to ensure that consumers enrolled in the plan have reasonable access to all covered benefits. This is what is meant by network adequacy.
As narrow provider networks become more common, health care consumers need accurate and more usable information about the size and composition of provider networks to make meaningful choices about health insurance.
Parity means that individuals have equal access to physical health and mental health/substance use services and treatments through their health plans. Insurance companies cannot place limitations or additional financial requirements on mental health/substance use services and treatments that don’t exist for physical health services and treatments.
In 2008, President Bush signed the Parity Act into law, which requires insurance companies to provide for mental health/substance use conditions equally to physical health conditions. However, it is up to each individual state to make sure insurance companies are following this law.
Parity violations occur when insurance companies do not provide mental health or substance use benefits equal to physical health benefits. Some examples include:
Pennsylvanians deserve better!
In order to enforce the federal Parity Act, Representative Tom Murt (R – 152nd Legislative District) recently introduced parity implementation legislation, House Bill 2173. This legislation will improve the lives of our family and friends by giving them access to the health services they need, enhance the state’s authority to monitor and enforce parity, and educate consumers about their rights. This bill does not create any new requirements for insurance companies, it simply holds them accountable for following the 2008 federal law.
PHAN supports HB 2173 and is committed to educating consumers about their rights. Contact us if you or someone you care about is having problems accessing mental health/substance use services and you think it might be a parity violation. We want to hear from you!
Patient Centered Medical Homes are doctor’s offices that make it easier to get all the health care you need.
In a Good Patient Centered Medical Home…
Our traditional model for affordable housing assumes that if you provide the physical space in which someone can live, they will overcome homelessness (i.e. “build it and they will come”). Driving this is a funding model that resources construction capital and operating costs. However, as we turn to address the issues of chronic homelessness, which are often compounded by serious and persistent mental illness, substance use disorder, co-occurring disorders, or multiple chronic physical health conditions, we know that simply having housing does not guarantee success. A new supportive housing services component needs to be added to the housing plan to ensure successful tenancy. The complexity of these populations also highlights the connection between health and housing. Safe, stable housing is a social determinant of health. A growing body of research indicates that health outcomes improve when someone has permanent supportive housing.
To fix the problem with funding, some states have already begun to turn toward using state Medicaid dollars to pay for supportive housing services for the chronically homeless who also have serious and persistent mental illness, substance use disorder, co-occurring disorders, or multiple chronic physical health conditions. States like Louisiana, Massachusetts, and Texas use their Medicaid dollars to pay for supportive housing services only. They do not pay for housing construction or rental subsidies. However, New York and California are moving toward paying directly for housing.
A campaign is currently working to press Pennsylvania to use state Medicaid dollars to fund supportive housing services. If you believe housing and health are important and interconnected, please contact Patrick Keenan for more information at email@example.com or (717) 322-5332.
You can join the campaign by completing this brief survey:
Passage of the Affordable Care Act (ACA) expanded insurance coverage for people with substance use disorders and improved the range of available treatment options and recovery support services. Many newly eligible individuals have enrolled in coverage since then, and countless others who already had insurance gained coverage for substance use disorders services for the first time. However, thousands more people living with substance use disorders or in recovery remain unenrolled.
To obtain comprehensive health care benefits, the uninsured must enroll in health insurance coverage. Reaching people with substance use disorders requires targeted outreach because the illness itself can create barriers to enrollment. Massachusetts’ experience with implementing a near-universal health insurance law shows the need for targeted outreach: Within four years of reforming the state’s health insurance law, 97 percent of Massachusetts residents were enrolled, but about 25 percent of those seeking treatment for substance use disorders remained uninsured.1
Impact of having a chronic illness
Addiction to drugs or alcohol is a chronic illness with symptoms that can make enrollment challenging, such as an inability to concentrate or retain information. It can also create barriers to maintaining employment, securing reliable transportation, or interacting with others.2 Many people with a substance use disorder also have a mental and/or physical illness, further complicating access to care.
Daunting application process
The length of time needed to process applications, complexity of the process, and requirements for documentation of income, citizenship, and residence can be challenging for anyone. Individuals with severe substance use disorders are vulnerable to experiencing homelessness and may have frequent changes to their mailing address or no address at all. These factors make it exceedingly difficult to get required documentation and to find a safe place to store these important papers.
Sporadic encounters with the health care system
Many people are expected to learn about ACA enrollment through their health care providers, but many individuals with substance use disorders do not have a regular health care provider, or may avoid seeking care. Health insurance is complex to navigate, particularly for people who have never before had coverage. People with substance use disorders may not know that they qualify for subsidized marketplace health plans, or that they are newly eligible for Medicaid. Many also do not know about the range of treatment options available to them, including integrated primary and behavioral health care, accountable care organizations and health homes that can help them navigate the health care system and coordinate care.
Misinformation about eligibility
Some formerly incarcerated people believe they are not eligible for coverage. In states where Medicaid eligibility is expanded, people leaving prison or jail who have low incomes will likely be eligible for Medicaid and subsidized private insurance plans. In all states, formerly incarcerated people who do not have health insurance coverage through a job and earn too much to qualify for traditional Medicaid can buy private insurance through the Marketplaces.3
While there is movement toward treating substance use disorders as a chronic condition, many people still blame those with substance use disorders for what they see as moral failings. Stigma contributes to people with this illness feeling shame, making it difficult to seek treatment for their illness.
PHAN is partnering with PRO-ACT and the Council of Southeastern PA to help individuals and families with mental illness and substance use disorders connect with new health insurance options under the new health care law, the Affordable Care Act.
Under this partnership, we’ve developed specific outreach materials to inform the recovery community about coverage, we canvas for the uninsured at recovery events, target community locations connected to those in recovery, partner with providers of recovery supports, and host educational sessions to broaden the knowledge base of the recovery community about coverage options.
This on the ground work teaches us about the specific barriers to care faced by those in recovery and helps us understand some of the next steps we need to take to ensuring those in recovery have high quality supports and services.
While the United States has some of the best medical resources (doctors, hospitals, resources), there are wide disparities in the quality of care different communities receive and we spend more on care than any other country in the world. We need to focus on the Triple Aim: improving care, increasing health outcomes, and reducing costs. To do this, it takes a coordinated effort among consumers, providers, drug companies, medical device manufacturers, and insurers to transform our health systems. Specifically, Consumers Union groups what we need to do into several buckets:
As we do these things, it’s important to ensure that consumers are engaged in the process and taken seriously, that we create a culture of care that is “person-centered,” that we incentivize person-centered care, that we ensure the proper resources and consumer protections are in place to improve outcomes, and that we address head on inequities in the system to ensure that all individuals can be healthy.
We need to tackle some key initiatives to delivers wins in each of the categories above. Some examples of work that can transform our current health system are:
1 Victor A. Capoccia, Kyle L. Grazier, Christopher Toal, James H. Ford II and David H. Gustafson, Massachusetts’s Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment. Health Affairs. 2012; 31(5): 1000-1008.
2 National Coalition for the Homeless: Substance Abuse and Homelessness.
3 Open Society Foundation, “Affordable Care Act (ACA) 101”
PHAN recognizes that Pennsylvania’s diverse communities have distinct needs and issues. For example, many disadvantaged communities – communities of color, low-income families, and LGBTQ Pennsylvanians – have worse outcomes and life expectancy than the rest of the population. Of the many factors that account for health disparities, the ones that are most amenable to change are those related to health and health care, specifically the way health care is delivered and experienced across cultural barriers.
The Affordable Care Act provides valuable tools to Pennsylvania for health equity. PHAN will continue to address the needs of Pennsylvania’s diverse communities, through language access, healthy equity, immigrant access issues, LGBTQ inclusion, protections for people with disabilities, rural health, women’s health and addressing the social determinants of health.
One of the biggest goals of the Affordable Care Act — aside from making coverage accessible to those who are currently shut out of the system now — was putting a bigger focus on wellness and preventive care by giving everyone better tools to keep themselves healthy.
While the Affordable Care Act stops insurers from denying LGBTQ people coverage, it doesn’t guarantee that important services they need will be covered. Too many LGBTQ Pennsylvanians routinely face judgment, bias and discrimination when attempting to access health care — and in Pennsylvania, there are no laws in place to stop it. That needs to change.
The Patient Protection and Affordable Care Act makes health coverage more secure by making sure no more families are denied care due to a pre-existing condition, or lose their coverage or be forced into bankruptcy when someone gets sick. The law includes many important benefits to enhance the quality of seniors’ care, while making things like prescription drugs more affordable.
In 2010, nearly 3.5 million people, or about 27 percent of the state’s 12.7 million residents, lived in Pennsylvania’s 48 rural counties (U.S. Census Bureau). Rural Pennsylvanians experience health disparities on multiple dimensions: they are less likely to have job-based health insurance, they may have to travel long distances to seek medical care, and they experience higher rates of chronic health conditions than their suburban and urban counterparts.
At PHAN, we believe in connecting people to health care, not handcuffs.
Law Enforcement Assisted Diversion, or LEAD, is a program that gives police officers the authority to divert individuals to a community-based, harm reduction intervention for violations that are largely driven by unmet behavioral health needs. This harm-reduction approach for responding to low-level offenses like drug possession, sales, and prostitution was developed and launched in Seattle in 2011. LEAD is an alternative to incarceration that connects individuals to a range of support services including case management, supportive housing, and mental health and substance use treatment.
Five cities have already launched LEAD programs, and nearly twenty more are in development and final implementation stages. In Seattle, LEAD participants were 58% less likely to be arrested, compared to those who went through the traditional criminal justice system (Lead National Support Bureau). The majority of LEAD participants experience mental health and/or substance use disorders.
The overarching goals of LEAD are to:
PHAN supports LEAD’s model of prioritizing health care over criminal prosecution. Together with local partners, PHAN is supporting the development of a LEAD program in Philadelphia. If you’d like to be involved in our Philadelphia efforts, please contact Patrick Kennan at firstname.lastname@example.org or (717) 322-5332.
To learn more about LEAD programs nationwide, click here.
We represent consumers—insured, uninsured, under-insured—at the Pennsylvania Legislature, at state agencies, in the media, and in public forums. The health care industry, from insurers to drug companies to doctors and hospitals, are well-represented at the Capitol. PHAN ensures that health care consumers voices are heard by policy makers. Check out our Legislative updates center for legislation we are tracking and its impact on Pennsylvania consumers.