Access Archives

Telehealth for people with disabilities: here are the challenges and opportunities policymakers should consider

Portrait of a man in a wheelchair on a laptop

Telehealth was a lifeline for people with disabilities during the COVID-19 pandemic. Federal and state policy changes allowed clinics, health systems, and providers to expand telehealth services, which benefitted people with disabilities.

People with disabilities, approximately one in every four Americans, are six times more likely to have ten or more physician visits and five times more likely to be admitted to a hospital. So there is a high need for accessible care.

Findings

Telehealth is known to:

Increase access to care by reducing transportation needs and wait times while increasing access to specialists in shortage areas.
Reduce costs by improving continuity of care, which lowers the likelihood of a high-cost care situation.
And promote independence by empowering people to manage their own conditions.

However, people with disabilities may find it difficult to access telehealth.

One Pew Research Center study found that people with disabilities were 20 percent less likely to own a computer, smartphone, or tablet compared to people without disabilities. And because 26 percent of people with disabilities live at or below the poverty line (2019) they can’t always afford high speed internet or advanced technology.

In addition, telehealth isn’t well designed for people with disabilities.

Older adults, people with intellectual and developmental disabilities, and people with cognitive impairments may need help with telehealth technologies.
People who are deaf, hard of hearing, deafblind, blind, or intellectually or developmentally disabled may find video communication platforms challenging.
Health systems and providers may not know how to set up and operate accessible digital systems.

Conclusions

Policy and decision leaders should consider the needs of people with disabilities as they review telehealth policies.

In this new brief, CHRT describes telehealth opportunities and barriers for people with disabilities. CHRT offers national and state policy suggestions to make these services more accessible, functional, and supportive for people with disabilities.

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Telehealth services have expanded to address COVID-19 emergency. Let’s preserve the most effective innovations.

Over the past decade, telehealth services have been on the rise, in part due to the fact that more and more states are adopting telehealth-friendly policies. But by 2019, the proportion of U.S. consumers using telehealth services was still only about 10 percent. In light of the COVID-19 emergency, national Medicare and Michigan Medicaid and commercial plans have responded with changes to coverage, opening up telehealth options to more consumers than ever before. Some of these telehealth innovations are beneficial and should be preserved even after the COVID-19 pandemic.

Some changes to telehealth in response to the COVID-19 pandemic will have a long term impact, such as the expansion of telehealth capabilities among providers. With funding from the Federal Communications Commission as part of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) providers can apply for funding to become better equipped to offer telehealth services, particularly in rural or medically underserved areas hit hardest by the pandemic.

Most of the changes to telehealth were designed to be temporary, effective only during the COVID-19 emergency period. However, we believe many telehealth innovations are worth preserving after the COVID-19 pandemic, especially changes that have improved care for patients with mobility issues or those who must travel long distances to see providers in person.

In this brief, we outline key changes to federal, state, and commercial telehealth policies and discuss challenges and opportunities for policymakers and decision leaders who wish to preserve telehealth access when the crisis is over. Among other concerns, access to the technology necessary to participate in telehealth is needed on both the consumer and provider side and still lags behind for important constituents—including some who have been traditionally underserved. And true commercial insurer payment parity policies also lag behind in most states. Payment parity would put telehealth on par with in-person visits to encourage providers to pursue telehealth as an option whenever appropriate, giving more options to consumers. Policymakers at every level will need to continue to address these issues to close the gaps in telehealth access and preserve the innovations the COVID-19 pandemic has caused.

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Acknowledgements: Special thanks to Dana Chesla-Hughes, program manager, behavioral health, Michigan Health Endowment Fund.

Access to health care in Michigan: Results from CHRT’s latest Cover Michigan Survey

The Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey asked Michigan residents about their experiences in accessing health care, specifically how easy or difficult it was to get appointments with different providers.

The Cover Michigan Survey found that two factors—the presence of primary care providers (PCP), and whether or not people had a medical home—figured prominently in reported ease of access to care.

Additionally, ease of access to health care can vary and is not uniform for all populations. Over time, the percentage of respondents reporting ease of access or access challenges has been relatively consistent, but uninsured people continue to face challenges in accessing care, and access to some critical services like specialty and mental health care continues to be a problem for key groups. The 2018 Cover Michigan Survey report examines important indicators of access: self-reported ease of accessing primary, specialty, mental health, and dental care, and forgoing necessary medical and mental health care.

People in Michigan have varying experiences in accessing care. The 2018 Cover Michigan Survey
examined those variations by a number of factors and found important disparities. Key findings
include:

Variations in access to care exist: Primary and dental care were the least difficult services to access while specialty and mental health care were reported to be the most difficult. One in five people reported not seeking necessary medical care in the last six
months and one in ten reported not seeking necessary mental health care in the last year.
Connection to primary care matters: In comparison to Michiganders who had a PCP, people without a PCP were more likely to forgo medical and mental health care, and report difficulty accessing all types of care. Nearly half of those without a PCP had difficulty accessing specialty care and mental health care.
Having a medical home matters: People who relied on hospital ER/urgent care and clinic settings as their routine location of care reported more difficulty accessing care, and were more likely to report forgoing medical and mental health care, in comparison to those whose usual source of care was at a doctor’s office. The largest gaps were seen in mental health care, with hospital ER/urgent care and clinic users being twice as likely to report difficulty accessing care compared to people who typically access care through a doctor’s office.
Differences in access by type of insurance are evident: People with Medicaid and individually purchased plans were more likely to report difficulty accessing specialty and dental care, in comparison to those with Medicare or employer-sponsored plans. However, Medicaid beneficiaries were least likely to report difficulty in accessing mental health care. People who remain uninsured reported the greatest difficulty accessing all types of care, and were also most likely to report forgoing medical and mental health care they believed they needed.

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Projected impacts of Medicaid work requirements: An overview of current state proposals

Several brown file tabs, with the center one reading "Requirements", referring to the new Michigan Medicaid work requirements.

As of January 2019, 14 states have submitted proposals to the federal government requesting permission to establish work requirements in their Medicaid programs. To date, the U.S. Centers for Medicare and Medicaid Services (CMS) has approved Medicaid work requirements for seven states, and two states (Arkansas and Indiana) have begun implementing these requirements for Medicaid beneficiaries. This overview examines the projected impacts of these Medicaid work requirements.

In June 2018, Michigan enacted work requirements for many enrollees in the Healthy Michigan Plan (HMP), Michigan’s expanded Medicaid program for low-income adults.

Beginning in January 2020, HMP enrollees under age 63 will be required to report 80 hours of work per month or obtain an exemption (see CHRT’s previous fact sheet, Proposed Medicaid Work Requirements in Michigan).

The Michigan House Fiscal Agency initially estimated that the impact of Medicaid work requirements would result in approximately 80 percent of enrollees subject to the requirements, while 20 percent would qualify for an exemption. More recently, an independent analysis by Manatt Health projected that 39 percent of HMP enrollees would be automatically exempt (based on age, pregnancy, medically frail, or incarceration status; or because they are already meeting SNAP/TANF work requirements), while 61 percent would be required to report work hours or obtain an exemption. This analysis estimated that 9 to 27 percent of all HMP enrollees could lose coverage over a one-year period.

Most of the 14 states that have requested federal permission to establish Medicaid work requirements have projected that some current Medicaid enrollees will lose coverage as a result of these changes. While estimates vary, states have projected that anywhere from 5 percent to 50 percent of the populations subject to work requirements (i.e., those who are not currently working and do not qualify for an exemption) are estimated to lose coverage. The Kaiser Family Foundation has estimated that, if a work requirement were implemented at the national level, approximately 1.4 to 4 million enrollees (6-17 percent of non-elderly, non-disabled adult Medicaid enrollees) would lose coverage.

Early experience from Arkansas indicates that administrative or structural barriers may prevent individuals from complying with work requirements. According to a recent report from the Kaiser Family Foundation, many Medicaid enrollees were unaware of the new requirements and unable to navigate the state’s online-only reporting system. In addition, enrollees may face a lack of jobs (especially in rural areas), transportation, and/or internet access to obtain information about job and volunteer opportunities.

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Cover Michigan Survey: Use of Health Care Benefits in Michigan

Data from the Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey show health benefits that Michiganders with health insurance coverage have used in the past year ⁽¹⁾Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.. Detail on the Cover Michigan Survey and analysis methodology can be found on CHRT’s website. In addition to findings on overall use of health care benefits, this brief focuses on three key areas: dental and vision, reproductive health, and mental health care.

Nearly all Michiganders used some kind of health benefit over the last year. To understand differences in the use of health care benefits, several variables were examined by demographics including gender, age, race, insurance type, income, and employment status.

Preventive care: The highest utilized benefit was routine, preventive primary care This was consistent across all groups.
Dental and vision care: There is high use of these benefits even though they are not generally core offerings of most insurance
Reproductive health care: Michigan women, especially younger women, use these health benefits at a significantly higher rate than men and older women. Reproductive health care represents 11 percent of younger women’s health care utilization.
Mental health care: Younger women and people who are unemployed reported significantly higher use of their mental health care or substance use treatment coverage.

Other findings include:

Aside from dental and inpatient care, women consistently utilized more health care benefits than men.
African Americans were the least likely to visit a doctor and use vision care benefits compared to other races, while white Michiganders were the most likely to use inpatient services.
Regardless of insurance type, respondents use doctor visits at similar rates, however those with employer-provided insurance were the most likely to use dental care health benefits.
Medicaid beneficiaries had the highest utilization of pediatric care, contraceptive/family planning, mental health/substance use, and maternity/newborn care benefits; and Medicare beneficiaries made the most use of the prescription drug benefit. These differences are likely due to the unique populations that make up membership in these plans.
Compared to those with lower household income, Michiganders with incomes of $50,000 or more per year were far more likely to use dental care, doctor visits, and vision benefits.
The unemployed population was more likely to use inpatient care, mental health/substance abuse services, and maternity/newborn care than those who are working or in school.

READ THE REPORT

References[+]

References
↑1	Survey participants were asked whether or not they or other family members covered by their plans used each health care benefit in the past 12 months.

Proposed work requirements for Medicaid in Michigan: June 7, 2018

A white sheet of paper with writing. A green highlighter is highlighting the word "legislation", referring to new Michigan Medicaid work requirements.

At the start of 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In the last five months, work requirement proposals have been approved in four states; formal applications have been submitted by seven more, and a number of others are preparing proposals. Michigan is among the states proposing Medicaid work requirements.

In April, the Michigan State Senate took the first step toward establishing work requirements by passing Senate Bill 897. The Michigan House of Representatives passed an updated version of the bill on June 6. And on the morning of June 7, the Michigan Senate approved the revisions and sent the bill to the Governor’s office for signature.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s most recent Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, Arkansas, and New Hampshire. We also describe new requirements for Healthy Michigan Plan enrollees who wish to maintain coverage after four years, and a series of triggers that would terminate the Healthy Michigan Plan if CMS fails to approve these requirements.

To learn more, read our Consumer’s Guide to the Medicaid work requirements.

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Setting the stage for the 2019 Health Insurance Marketplace

The Centers for Medicare and Medicaid Services is rolling back regulations around rate increases, essential health benefits, health insurance navigators, and more, for insurers offering Qualified Health Plan coverage on the Health Insurance Marketplace in 2019.

On April 9, 2018, the Centers for Medicare and Medicaid Services (CMS) issued new guidance for insurers offering Qualified Health Plan (QHP) coverage on the Health Insurance Marketplace created under the Affordable Care Act. In this guidance, CMS made several important changes intended to provide states with greater flexibility to regulate their individual and small group health insurance markets beginning in 2019.1

In a new fact sheet, CHRT compares the current rules and regulations to the changes that go into effect in 2019—with a special focus on Michigan. The face sheet reviews essential health benefits, health insurance navigators, maximum out-of-pocket limits, standardized plan options, rate increase reviews, medical loss ratio, risk adjustment, silver loading, individual mandate hardship exemptions, projected premium and federal spending changes, and the timeline for the 2019 filing process in Michigan.

Here are just a few highlights:

Rate increases under 15 percent will no longer require review;
Simple choice standardized plans will be eliminated; and
Consumer cost-sharing limits will increase by 7 percent.

These changes to the 2019 Health Insurance Marketplace will impact Michigan consumers as soon as November 1, 2018, when the next Marketplace Open Enrollment Period begins.

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Update: For more information about the 2019 Health Insurance Marketplace, read our rate analysis.

Proposed work requirements for Medicaid in Michigan: April 20, 2018

A stack of red and yellow files and notebooks. On the top notebook, "Proposal A-2136" is written in black marker, referencing Michigan's proposed Medicaid work requirements.

At the start of 2018, the U.S. Centers for Medicare and Medicaid Services announced a major shift in federal policy that would allow states to request permission to establish, and test the impact of, work and community engagement requirements for able-bodied adults receiving Medicaid health insurance coverage. In early March, Michigan state senators took the first step toward preparing a Medicaid work requirement proposal of their own by introducing Senate Bill 897. The bill passed the Michigan State Senate on April 19.

In the last three months, work requirement proposals have been approved in three states; formal applications have been submitted by seven more; and a number of others are preparing proposals.

In this fact sheet, we compare the characteristics and projected impact of Michigan’s Medicaid work requirement proposal against the characteristics and projected impact of approved work requirement proposals in Kentucky, Indiana, and Arkansas.

The characteristics we compare include: target Medicaid populations, Medicaid enrollment, populations exempt from the new work requirements, the hours of work required, activities counted as work, and loss of coverage rules. It is difficult to project the impact of work requirements on the Medicaid population because there is no precedent program, but we discuss some possibilities.

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For updated information, read our article from June 7.

Health Insurance Marketplace in Michigan 2018: Rate Analysis

In 2017, the federal government took several regulatory and administrative actions that affect the health insurance marketplaces created under the Affordable Care Act (ACA). At the same time that Congress considered legislative proposals to repeal and replace the ACA, the U.S. Department of Health and Human Services (HHS) promulgated new regulations that changed annual open enrollment dates and announced the end of cost-sharing reduction payments to insurers. These developments, in addition to several other factors, have impacted Marketplace carrier participation and plan pricing in Michigan. This brief analyzes the rates in the 2018 Health Insurance Marketplace in Michigan.

Key findings include:

Michigan continues to have a robust Marketplace. Eight insurers are participating in Michigan’s health insurance marketplace in 2018, a decrease of two insurers from 2017.
Michigan consumers can select from a variety of Marketplace plans. There are 12 to 52 plans offered in each of Michigan’s 83 counties.
Across all counties, the average premium increase for the lowest cost and second-lowest cost silver plans is 33 percent and 34 percent, respectively. Premiums for the lowest cost bronze plan increased by 16 percent, and premiums for the lowest cost gold plan increased by 6 percent.
Premium tax credits are linked to the cost of the local second-lowest cost silver plan. All else equal, individuals who are eligible for premium tax credits could receive a larger tax credit in 2018 due to premium increases for the second-lowest cost silver plan. In 23 counties, larger tax credit amounts will eliminate the cost difference between renewing the 2017 lowest cost silver plan and actively enrolling in the 2018 lowest cost silver plan.
The federal government reduced the open enrollment period to 45 days, from 92 days in 2017.
Federal financial support for Michigan Navigators to help with open enrollment has been reduced by 72 percent, from $2,228,692 in 2017 to $627,958 in 2018.

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Comparing Key Provisions: Affordable Care Act, American Health Care Act, and the Graham-Cassidy Proposal

In July 2017, the United States Senate rejected a series of proposals to repeal and replace the Affordable Care Act (ACA). On September 13, 2017, Senators Lindsey Graham and Bill Cassidy introduced a new proposal to repeal and replace the ACA.

The Graham-Cassidy proposal retains some similarities to the American Health Care Act, which passed the U.S. House of Representatives in May 2017, but includes some notable differences. This brief compares key provisions of the Affordable Care Act, American Health Care Act, and the Graham-Cassidy proposal.

The Senate has until September 30, 2017 to pass a repeal and replace package under the Fiscal Year 2017 budget reconciliation process, which requires a simple majority for passage. After the end of FY 2017, any repeal and replace legislation would most likely require 60 votes for passage. It is possible that budget reconciliation, requiring a simple majority for passage, could be used for repeal and replace legislation in FY 2018 if it is not used for other issues.

On Sept. 25, the U.S. Congressional Budget Office (CBO) issued a preliminary report on a version of the Graham-Cassidy proposal summarized in this brief. The CBO concluded that the bill would save at least $133 billion. However, it would result in millions of people losing health insurance. Additional, detailed analyses may be forthcoming.

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Publications

Findings

Conclusions