Workgroup - BOI Meeting, August 11

At the Direct Care Worker Health Insurance Workgroup meeting with the Bureau of Insurance on August 11th, MSEA-SEIU Local 1989 presented a health insurance product that is available to SEIU members. This plan covers doctors' visits, some radiology exams and some lab tests. It does not cover hospitalization should a policy holder require it. There are no pre-existing exclusions. It also has dental coverage if the policy holder so chooses. It is a limited benefit plan, not comprehensive or catastrophic. This plan is basically for those who are relatively healthy and want a little help with those annual physicals and doctors' visits if something should come up. I'm not sure if a bone got broken, how this plan would work. Prescriptions are not covered. This plan is administered through SEIU, a third party trust that is part of the Union Trust. It is approved through Aetna, not SEIU. This plan comes in three tiers, A, B and C with a dental rider. I am not sure what the three tiers are or what they offer. I know that MSEA-SEIU is looking into to this for 771 and Childcare members. This plan may be offered as single, self-insured, it is not offered through contract negotiations yet. After the SEIU plan was presented, there was a lot of discussion as to affordability. The next phase of the meeting was identifying issues pertaining to Direct Care Workers and health insurance. These issues brought forward were: accessibility, eligibility; affordability; benefit design, education, marketing; wellness. The insurance codes that BOI presented at an earlier session were also presented again. One option that decidely is not for DCWs is the Multi-Employer Welfare Arrangement (MEWA) because employers pool risk making each responsible for liabilities. BOI also presented possible options for us to work with. DirigoChoice showed up in these options many times. I spoke up and said that Direct Care Workers lost their bid for DirigoChoice, through LD1687, because of funding problems for Dirigo. I said that was why we were all at the table, trying to come up with a different solution to gain health insurance for Direct Care Workers. Elise Scala from the Muskie School urged folks to remember that the Direct Care Worker Coalition focused their efforts on Dirigo because of the program's design. The sliding scale on premiums based on income would work well for Direct Care Workers. On this I agree. Dirigo's sliding scale would work great for us Direct Care workers. Again, the problem is funding. Elise also recommended that the report to the Insurance and Financial Services Committee make mention of Dirigo's design in an effort to make premiums affordable. Joanne Rawlings-Sekunda and Deputy Superintendent Judy Shaw urged us all to start thinking about what we want going into the report for IFS. The next meeting to start doing that work is Wednesday, August 20th, 10-12 at the Bureau of Insurance Office on Northern Avenue in Gardiner. The public is welcome. If you're interested in attending and want more information or directions, please send an email helen.hnsn@gmail.com. If your want more information on the SEIU plan, please use my email or call MSEA-SEIU Headquarters at 1-800-452-8794 and ask for Mike Sylvester.

Coverage Models Presented to Summer Working Group - July 30, 2008

Last Wednesday (Jul. 30), the summer working group heard presentations on four models for health care coverage, three for members of a specific workforce and one for employees of small businesses. It also heard an argument for tailoring a health care plan to address obstacles encountered by all low-wage workers, not just one particular workforce. Coverage models The first model concerned the Maine State Chamber Purchasing Alliance. As explained by Dana Connors, the president of Maine’s State Chamber of Commerce, the principal features of the model include: It is available to small businesses with 2-50 employees It creates seven different plans for employers to offer It received a Bureau of Insurance (BOI) waiver to reduce required employee participation rate from 75% to 60% A wellness discount of 2% of premiums is available to businesses whose employees participate in special health programs This set-up is apparently useful for some 480 Maine businesses insuring some 3200 folks, but its rates are similar to “community rating” rates available in the general market, so it doesn’t help much with affordability. Mollie Baldwin, the CEO of Home Care for Maine, also noted that this kind of system does nothing for larger employers and their workers. The second model presented was that of the Maine Bar Association. Here, a group of businesses has pulled themselves together to form a risk pool. Because these lawyers felt they were likely to be healthier than the general community, they sought to make use of BOI rules allowing them to be rated separately from the community rating system. For a while, this brought down premium costs. However, when several employees became severely ill and ran up high costs, insurers significantly boosted the association’s premium costs at time of renewal. With that, several large employers withdrew from the association, decreasing the size of the pool significantly, so premiums went up again. This option would not be particularly attractive in any event for long-term care employers, since direct-care workers tend to be older and more injury-prone than the general population. Both of these models fail to address the basic underlying issue: cost. A 2% wellness discount is good, but it won’t make up the difference between high premium costs and low wages for direct-care workers. Toward the end of the meeting, Elise Scala and I presented brief overviews of experiences from other states, both of which are highlighted in Coverage Models from the States (pdf). I went first and talked about Montana and Rhode Island. In Montana, recent legislation singled out direct-care workers for special attention. The state will increase Medicaid payments to home care agencies that make affordable coverage available to their employees. The details are still under discussion, but the plan is supposed to go online in January 2009. Several summer meeting participants voiced interest in this model, which transfers a very large portion of the subsidy costs to the federal government through the Medicaid matching dollar program (in Maine, the feds provide 66% of all funding for Medicaid expenditures). The group plans to discuss this further at the next meeting. In Rhode Island, the state singled out child care providers as eligible to join a state health insurance program. Depending on income, the state requires these workers to contribute between $61 and $130 a month. As in Montana, the program is subsidized through Medicaid, transferring a significant portion of the cost to the federal government. Elise spoke briefly about models that focus not on individual groups of workers but on the obstacles that prevent direct-care workers from acquiring coverage. Tailoring programs to these common obstacles and thus making them accessible to all low-income workers, she said, would probably reduce political opposition – and ultimately increase coverage for direct-care workers. Talking strategy After the general BOI meeting, a small group from the Direct Care Worker Coalition spent an hour in a wide-ranging talk with Mila Kofman and Judy Ward, the Superintendent and Deputy Superintendent of Insurance. Both Mila and Judy listened carefully to our concerns and seemed genuinely interested in helping us find ways to move our agenda forward. Mila, coming from a federal background, was focused on federal options we might explore, including possible increases to Medicaid’s SCHIP program, which she felt might be used to increase Medicaid funding and ultimately reimbursement rates. She also mentioned a new initiative co-sponsored by Sen. Durbin and Sen. Snowe, the SHOP Act, which would allow small businesses to band together in a larger risk pool in order to obtain lower premiums. The SHOP Act would provide employers with significant tax credits if they cover their employees. It probably isn’t an immediate or complete solution for direct-care workers, but it may help some employers overcome the financial barrier to providing affordable coverage. Mila and Judy both expressed an interest in scheduling a longer meeting to delve more deeply into the obstacles to coverage, the complicated interactions between reimbursements and coverage, unemployment insurance and injury rates. We expressed a desire to hear more about their thoughts on state-level policy and/or code-related options on which the Direct Care Worker Coalition might focus its future efforts. Though no immediate solutions emerged from this meeting, I think it is fair to say that it was quite productive and moved the Direct Care Worker Coalition very much into the thoughts of both of the BOI’s top administrators. At the next meeting, I believe the plan may be to have more open discussion of the solutions presented to date, and perhaps some discussion of Dirigo. Judy also hopes to begin discussing the kinds of recommendations the group will want to see included in the final report.

Kurt Wise

Financial Analyst

Maine Center for Economic Policy

kwise@mecep.org

Workgroup - BOI Meeting, July 30th

The Direct Care Worker Workgroup meeting with the Bureau of Insurance on July 30th went well. BOI asked the Maine State Chamber to present information on their purchasing alliance. What this particular alliance does is allow companies who are members of their local chamber of commerce buy into the group health insurance that is purchased by the alliance. These companies pay a yearly membership to the alliance. That fee goes to cover the administrative costs of the alliance. Ninety percent of the companies in this alliance have fewer than 50 employees. The participation rate is sixty percent. That makes a significant difference in whether or not the companies can utilize this alliance. The sixty percent participation rate means that the companies need to have sixty percent of their employees use the coverage in one form or another in order to participate in the plan. Another thing that struck me was the flexibility of the insurance plan. Employees have the option of choosing a plan that best suits their needs. Someone who is healthy and does not see their doctor often can opt for the health savings plan where someone who has small children can opt for an HMO plan. This alliance is also community rated and this is also attributed to its success. On the down side was the fact that most of these companies have 50 employees or fewer. A second BOI code was presented. That was the Maine Bar Association. This association was created with the sole purpose of buying health insurance for lawyers and their staff. This association is large, made up of 400 members. It is treated as a large group. Base rates are the same for all members in the group. The association is not community rated, it competes with community rated options. Small and large businesses participate, one having 1,500 employees that are insured. The association offers four to seven insurance products. Examples of associations to purchase health insurance are the Maine Medical Association and the Maine Dental Association. After discussion on this code, Kurt Wise of MECEP and Elise Scala of the Muskie School, both members of the Maine Direct Care Worker Coalition, presented information on what other states are doing in gaining health care coverage for their direct care workers. Kurt pointed out that states like Rhode Island and Montana have chosen to single out certain workforces that they feel are important to the overall health and well-being of their states. Rhode Island created a special program to help cover child care workers. Montana enhanced Medicaid payments to homecare providers that provide coverage to workers. The employer has to demonstrate that the money is going to providing health insurance for its workers. Other states are singling out their direct care workers as a viable, needed, important workforce; states like Iowa, Montana, California, New York. Elise brought attention to HCHCW's Coverage Models from Other States (http://hchcw.org link at right as well) and pointed to Iowa and its Health Care Reform Bill. Part of this reform requires Iowa's Department of Public Health to expand efforts to insure that a well-qualified and stable health and long-term care workforce exists. A Direct Care Worker Compensation Committee will be set up to make recommendations to increase worker wages and other forms of compensation. A pilot project will also get under way to provide health care coverage for up to 250 direct care workers and their families. This will be done by the Department of Human Services in an effort to see how this coverage will help workers and see if there's an impact on the turnover rate. There was some discussion on the SEIU plans that are covered in that booklet from Health Care for Health Care Workers. Maryanne Turowski from MSEA-SEIU Local 1989 will bring in information on those plans and on a plan that is in the works for its child care members and for 771 to the next BOI meeting. That meeting is scheduled for Monday, August 11 at the Bureau of Insurance in Gardiner from 9 - 11. Again, the public is welcome. Please contact me helen.hnsn@gmail.com for more information or directions.

Workgroup – BOI Meeting, July 14, 2008

This last meeting of the Direct Care Worker Workgroup and the Bureau of Insurance was an informative one in that the spotlight was on direct care workers and their employers. Elise Scala from MainePASA and the Muskie School of Public Service at USM and Kurt Wise from MECEP talked about statistics pertaining to the direct care workforce. Things like the number of workers that receive some sort of assistance like MaineCare, the number of hours workers get a week and the fact that many workers do not want more hours because they may lose their MaineCare eligibility. It was mentioned that 72% of workers are part-time. Employers were represented by Joan Donahue Thompson from Hummingbird Home Care, Mollie Baldwin from Home Care for Maine, Eunice Spooner from Alpha One and Mary Lou Dyer from the Maine Association for Community Service Providers. They said that employers don’t find it financially feasible to provide insurance to their direct care workers because of low reimbursement rates. Employers also stated that the ones that can afford to provide health insurance can only cover their employees, not employees’ families. It was mentioned that the lack of benefits is also a concern for consumers. When workers worry about coverage or their health, they talk about it with people around them and their consumers. That in turn makes consumers worry. Joyce Gagnon from MainePASA and I talked about the challenges direct care workers face. Low wages, no benefits, being tied to the state budget and its shortfalls. I mentioned the cut to the homemaking program and that it meant a cut in hours each consumer receives which in turn equals a cut in wages for workers. I also said that it is a grave injustice to this workforce that we are not eligible for health insurance through the work we do. Several mentioned that the reimbursement rate paid by MaineCare is too low. MaineCare reimbursement for Direct Support Professionals used to include a line item for health insurance, but like everything else tied to the state financially, it got cut a few years ago. A suggestion was made to create a risk pool of all direct care workers in Maine. Why not? There are a lot of us out there across the state. The obstacles come when addressing the way to pay for it and with the different codes BOI set before us at the July 1st meeting. I’m hoping this meeting was an eye-opener for those around that table that don’t know too much about the Direct Care Workforce here in Maine. The next meeting is scheduled for July 30, 2008 at BOI in Gardiner. The meeting time is 9-11. The meeting is open to the public. If you’re interested in attending and need directions or more info on the workgroup, please send an email helen.hnsn@gmail.com.

Health Insurance Workgroup Receives Press Coverage in Waldo County

Legislature taps group to explore health coverage for direct-care workers By Victoria Wallack, State House Reporter The Republican Journal AUGUSTA (July 16): A special committee created by the Legislature is looking for ways to provide health coverage to workers who take care of elderly and disabled in their homes or in institutions — jobs that largely are paid for by Medicaid, but either don’t offer health insurance or pay enough to allow workers to buy it. The original proposal that never made it to the floor for a vote this year was to put the workers in DirigoChoice, the state subsidized health insurance plan. That plan is facing its own financial difficulties, however, and for now enrollment is closed. The Insurance and Financial Services Committee voted instead to ask the state’s Bureau of Insurance to look at ways of making sure that more than 22,000 direct-care workers in the state have insurance and how to pay for it. The bureau has created the Direct-Care Workforce Health Coverage Working Group to help with the task, and it is meeting this summer. Funding no doubt will involve taxpayer dollars — either through a direct health insurance subsidy or by raising the Medicaid payments to the institutions and agencies that employ direct-care workers so they can offer insurance. The rate of uninsured ranges from a high of 34 percent for some home-based workers to 16 percent for those working in nursing homes and residential care facilities, according to a survey of some of the larger health-care providers. The number of uninsured correlates to low wages. Median wages in the direct-care industry range from $8.58 for home-based workers to just more than $10 for those working in long-term care institutions. Outgoing Senate President Beth Edmonds sponsored the legislation that would have put direct-care workers in Dirigo but said health insurance is just part of the problem. The overriding issue is making sure they earn a decent wage, she said. “I just want to make sure that we as a state keep trying to figure out how to raise the income of these people,” Edmonds said. “One, it’s the right thing to do and two, it’s a very important piece of the workforce that we need to make sure is stable and surviving.” Advocates argue that if wages and benefits aren’t increased, the state will not have enough workers to take care of Mainers in their homes as they age. The state has the highest median age in the country, and by 2030 will have 26.5 percent of its population age 65 or older, putting it second behind Florida. Mila Kofman, the state’s new superintendent of insurance, said her goal is “getting every single long-term care worker and their families insured.” “I’m not taking anything off the table,” Kofman said, including DirigoChoice as an option for coverage. She agreed that public funds most likely will be part of the proposed solution. "I think it’s realistic to say that for moderate-income wage earners, current prices of private coverage make it very difficult to buy purely private coverage,” she said. The bureau is due to report back to the Legislature by Oct. 1, and any proposal would require legislative approval. Rep. Jonathan McKane, R-Newcastle, who serves on the Insurance and Financial Services Committee, voted against creating the bureau study, saying direct-care workers don’t need to be singled out. “We all need health insurance and direct care workers are, of course, important. But, we need to make insurance affordable for everyone, not just certain groups. The government is kind of choosing the winners and losers,” he said. The Maine State Employees Association and its national parent, the Service Employees International Union, have gotten involved, organizing the Maine Direct Care Workers Union to lobby for pay increases and insurance coverage. Union spokesman MaryAnne Turowski, who serves on the health coverage working group, said the issue is inequity. “Our concern is these are health-care workers delivering health-care services, often with public dollars, and they don’t have health-care themselves,” Turowski said. The SEIU, with its local affiliates, is targeting lower-income service providers nationwide as part of its organizing efforts. Not only have they organized direct-care workers, but last year they organized home-based child-care providers — the majority of whom have state-funded care contracts. The Legislature earlier this year voted to recognize the new child-care union as a bargaining unit."

Second Meeting with Superintendent of Insurance

The second meeting was today with Deputy Superintendent Judy Shaw. Ms. Kofman had a prior engagement. This session consisted of the Bureau of Insurance putting forth Maine insurance codes options. There were seven code options that were discussed. Some made good sense, some made none at all, where direct care workers are concerned. The options presented were: Private Purchasing Alliance, Small Group Health Plan, Multi-Employer Welfare Arrangement (MEWA), Trustee Group, Labor Union Group, Association Group and Other Group. The Private Purchasing Alliance is a corporation that is set up to provide health insurance to its members through one or more affiliated carriers. There are certain insurance laws and rules that the corporation operates under. One nice thing about this is that it can include workers who are not affiliated with an employer, like our Alpha One folks. These unaffiliated workers do become a separate risk pool. I hate that term "risk" but it is term that insurance companies use. A risk pool is a rated group of individuals. It has nothing to do with how "sick" that group is. I think it has to do with the type of work you do, your age and possibly where you live that puts you into a certain "risk" pool. I think SEIU Local 503 in Oregon has set up its health insurance for its members this way. The Small Group Plan is one that is for employers with 50 or fewer employees. One drawback with this is that insurance companies require that 75% of all eligible employees have to participate in the plan. One plus is that eligible employees must work at least 10 hours per week. Community rating applies to these plans. Community rating is that rates cannot differ based on health status. This would be something that would work for Direct Care Workers. The Multi-Employer Welfare Arrangement did not seem like a good way to go. Those employers in the arrangement pool their risk and collectively self-insure. They create their own healthcare insurance plan. The MEWA defines what the plan looks like and what it offers and what the rates are. A big draw-back of MEWAs are that the employers in the arrangement are held liable for the obligations of the MEWA. If the MEWA cannot pay its obligations, the member employers pay an assessment. Another draw-back, those who are not employed by an employee of the arrangement cannot get coverage. A Trustee Group is a group of individuals insured under a policy that is issued to a trust that is established by two or more employers or by two or more labor unions or similar worker organizations. The trust is the policy holder. Those eligible are all the employees or the employer or all the union or organization members. SEIU Local 775 out in Washington has set up its healthcare insurance this way. The group wanted more information on this. Labor Union Group was the next code. The union/organization is the policyholder and those members of that union/organization may be insured. This group may not be eligible for small group community rating. More information was requested for this code. Association Group is a lot like the Labor Group in that a group of individuals may be insured under a policy issued to an association or a trust. The association must have at least 50 people. It must be organized and run in good faith for other purposes, not for just buying insurance. It must be in existence for at least two years before obtaining insurance. The association is the policyholder. The insurance is available to individuals and employers. The last code was Other Group. This is a group formed under 2808, an insurance law or rule. The only thing I have on this is that Dirigo is an example. Under the Small Group Plan, there was discussion as to the definition of employee in the purposes of insurance code. The group will hear from someone in the Department of Labor on that definition. You wouldn't think it would or could be so complicated, but it definitely is. Either you're working for an agency that matches you up with consumers, and that agency runs payroll to pay its workers; or you work independently, directly for a consumer. That consumer handles your payroll and workmen's comp. Either way, you're an employee. There was talk of "underground employees," those who are matched up with a consumer and unknowingly to the consumer, the consumer bears the burden of insurance and comp. All in all this meeting went well. There was concern that workers themselves were not being considered, it was mostly employers that were. My take was that the Insurance Bureau was giving us some tools to work with. The next meeting is scheduled for Monday July 14th at 10 am at the Bureau of Insurance Offices in Gardiner. These meetings are open to the public. If there are any direct care workers out there, interested in attending, please get in touch with me helen.hnsn@gmail.com I can fill you in a little on what the next meeting will be about and how this is all working.