The Messenger Also Matters: Value-Based Payment Can Support Outreach To Vulnerable Populations


The following excerpt comes from the July 10, 2017 article by Ruth C. Browne, Marilyn Fraser, Judith Killen, and Laura Tollen on the Health Affairs Blog.

With the proliferation of value-based payment initiatives and implementation of the Affordable Care Act’s (ACA’s) coverage expansions, states have had many opportunities in recent years to improve the health of vulnerable populations through health promotion, prevention, and care coordination. We believe value-based payment models can and must support accountable health care delivery systems in partnering with community-based “messengers” to engage vulnerable individuals in health education and promotion. We explore one such messenger program, ACCESS, a Brooklyn-based project of the Arthur Ashe Institute for Urban Health, which trains barbers and hairstylists to help formerly incarcerated men learn to recognize and act upon their own health risk factors. Value-based payment offers an opportunity to support programs such as this.

“Messengers,” as we define them here, are community health workers—those who serve “as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.” Unfortunately, there are few dedicated funding streams available to support the messenger role. Fee-for-service payment arrangements do not reimburse these activities. Value-based payment, on the other hand, not only highlights the need to support messengers but also potentially provides funding to do so.

Value-based payment programs hold the health care delivery system accountable for meeting health goals for entire enrolled or attributed populations, which requires more than just providing better medical care. Shortfalls in medical care are responsible for only an estimated 10 percent of early mortality in the United States, while individual health-related behavior is responsible for 40 percent. Even the finest delivery system can only expect to see a modest improvement in the health of its community if it focuses only on the very thing it has been designed to do—providing medical care to sick people. Value-based payment requires delivery systems to redefine nothing less than their product, place, and providers. The product must be health; the place must be where people live and work; and the providers must include credible, community-based messengers.

Credible messengers can bring to delivery systems important knowledge about social determinants of health that impact individuals’ ability to access and act upon health-related information. We focus here on one social determinant—incarceration. Individuals formerly incarcerated have become eligible for Medicaid in large numbers and, as such, participate in a variety of value-based payment initiatives. New York State, where the ACCESS program has been implemented, is moving aggressively toward value-based payment in Medicaid. In 2015, the state announced its intention to shift 80–90 percent of its Medicaid managed care provider payments from fee-for-service to value-based arrangements by 2020.

In the United States, nearly 700,000 state and federal prisoners are released annually, and more than 11 million cycle through local jails. Incarcerated individuals have poorer physical health status than the rest of the population, a high burden of mental health and substance abuse disorders, and, once they are released, are more likely than the general population to be uninsured. However, under the ACA, more than one-third of inmates released annually from state and federal prisons are estimated to be Medicaid-eligible. If this pattern holds true for those released from local jails as well, there are potentially millions of formerly incarcerated individuals newly eligible for Medicaid—and for the value-based payment initiatives that may come with it.

The burdens of incarceration are distributed unevenly. Sixty percent of New York State prisoners come from New York City, and two-thirds of the 28,000 people released each year return to the city. Some Brooklyn neighborhoods have especially high incidences of incarceration and concomitant prison spending, earning them the dubious honorific of “million-dollar blocks,” even though they are among the poorest neighborhoods in Brooklyn.

At the Arthur Ashe Institute for Urban Health (AAIUH), we found a striking overlap between Brooklyn’s million-dollar blocks and areas where we were already engaged in health-promotion activities. Founded in 1992, the AAIUH is an independent, nonprofit organization that collaborates with community members to incubate, test, and replicate neighborhood-based interventions to improve health conditions disproportionately affecting minorities. Arthur Ashe, a world-renowned African American tennis champion and social justice advocate, founded the AAIUH in partnership with the State University of New York Downstate Medical Center. Using community-based participatory research, the AAIUH navigates disparate worlds—the institutional universe of academic medicine and day-to-day life in multi-ethnic, multi-linguistic neighborhoods.

Among other projects, the AAIUH has a long history of training barbers and hairstylists to deliver health education related to breast cancer, cardiovascular disease, asthma, and diabetes in women, and HIV/AIDS and prostate cancer in men. When we began the ACCESS program in 2009, exploratory work revealed that more than 80 percent of barbers working in our ongoing projects had themselves spent at least one night in jail. This made them particularly credible messengers for our priority population of formerly incarcerated men and the supportive women in their lives. Guided by input from a community-based advisory board, we conducted focus groups of barbers, stylists, and customers to determine the best way to discuss incarceration and health, and which health issues would be most important to the community. Based on that input, the program emphasized cardiovascular disease, stress, and HIV/AIDS. We developed a health curriculum to increase awareness of these conditions, emphasizing prevention and the importance of “knowing your numbers”—that is, understanding health indicators such as blood pressure and cholesterol levels. The curriculum included a resource guide for community health and social services related to the priority conditions and services for the re-entry population.

We trained barbers and stylists to deliver the curriculum in six establishments in the Bedford-Stuyvesant and Crown Heights areas of Brooklyn, emphasizing that health messages must be delivered in a way that could be useful to any member of the community who might know someone who had been incarcerated, instead of focusing solely on the formerly incarcerated themselves. In addition to the health messages and the resource guide, ACCESS included an HIV-focused health education video played several times a day in participating salons and barbershops and 12 AAIUH-sponsored Health Resource Days held at these establishments.

The project evaluation consisted of pre- and post-intervention surveys of patrons. The pre-intervention survey assessed patrons’ familiarity with risk factors, prevention, and resources related to the priority conditions. For example, patrons were asked multiple-choice questions such as: “What are some of the warning signs of a heart attack? What is a normal blood pressure reading?” The post-intervention survey of the same individuals sought to determine whether they had been exposed to the intervention and whether their knowledge regarding any of the previously asked questions had changed. Survey respondents’ ability to identify ways to assess their cardiovascular disease risk increased from 44 percent to 62 percent, and understanding that condom use can decrease the spread of HIV increased from 77 percent to 88 percent.

Read the full article.

Glimpses of Community Engagement

Community engagement calls for cultural humility, patience, and the building of authentic relationships. In a series of short videos from the Division of Community Engagement at Virginia Commonwealth University, faculty members describe their personal experiences of working with community partners. The six videos discuss:

  • Why community engagement?
  • Cultural competencies
  • Community partners as co-educators
  • The nontraditional learning script
  • Why I identify as a community-engaged scholar
  • Breaking Down Silos

The videos are all available on YouTube.

CAB Member Profile: Reverend Michael Johnson


Reverend Michael Johnson

The Sentinel Surveillance to Monitor Progress toward Health Equity project aims to develop and implement a surveillance system to capture the information necessary to monitor progress towards health equity for health disparate populations. One key element of this project is the engagement of community members through a Community Advisory Board (CAB).  Recently, Reverend Michael Johnson, pastor of Faith Lutheran Church in Mobile, shared a little about his experiences with the CAB.


Tell us a little bit about yourself and your background.

I was born in Mobile and attended local public schools. After high school, I attended Bishop State Community College and, then, the University of South Alabama where I studied Civil and Structural Engineering. I completed my Master of Divinity at Concordia Theological Seminary in Fort Wayne, IN.  Before my pastorate here in Mobile, I pastored churches in Detroit, Birmingham, Memphis, and Baltimore.

How did you become involved with the Community Advisory Board for the Sentinel Surveillance Project?

I became involved by request of a previous [research office] employee, Andrea Hudson. She was aware of my years of community activism and involvement in providing initiatives for change.

Why did you decide to become part of the CAB?

We need to address the health disparities that cause much brokenness in our communities.  Participation in the CAB offers an opportunity to participate in important research that helps us understand these disparities and help mend the brokenness in our community.

Give us a few highlights of your time as a CAB member. Is there any one memory that stands out?

I appreciate the meetings, brainstorming ideas for effective health change, workshops and collaborating with others of the interest. If I had to identify a single memory/experience that has piqued my interest the most, that would be my recommendation and participation in the Bayou Health Disparity Fellows Program, of which I graduated May 9, 2017.

What community needs are you most concerned about?

Health Disparity change, diabetes, hypertension, obesity, drugs and alcohol addictions.

How do you see the sentinel surveillance project addressing these issues in the community?

Specifically, Dr. Arrieta’s sharing of information discovered through the research and community experience helps to educate also. Because of her personal interactions, it allows us to build relationships that are loving and caring for one another.

Have you ever been involved in research before, if so how is this similar or different?

I have been involved with research before on the data collection side. I desire to extend my interest is collaborating in academic, clinical trials and community samples through education and photovoice.

What have you learned about research through this process?

I learned that there are many causes of Health Disparity. There are also, needs and means for change, including policy change that would dissolve determinants causes.

Has the experience changed the way you consider or approach research in other areas of your life?

Yes, my viewpoint has changed tremendously. I am better educated and more motivated to be involved in the partnership and seeking means for health change for self and community.

Would you encourage others people in your life to participate in or be a part of leading/shaping research projects as a result of your involvement with Sentinel Surveillance?”

Yes, would definitely as I am encouraging others to get involved, get educated, participate and share in the movement of better health – better life.

American Health Values Survey

The following comes from an article by Larry Bye and Alyssa Ghirardelli for the Robert Wood Johnson Foundation.

How we think about health—and the values, beliefs, experiences and attitudes that shape our thinking—affect how we approach our personal health challenges, as well as those that face society. Factors influencing health are equally complex—from access to quality care, to how individuals approach and manage health, to social determinants like access to housing and transportation.

The Robert Wood Johnson Foundation worked with researchers from NORC at the University of Chicago to better understand the extent to which health is a shared value in the United States.

The resulting American Health Values Survey examined insights from more than 10,000 adults around their values and beliefs related to health at both the individual and societal levels, including:

  • How health-conscious are we in our day-to-day living—from exercise to diet to getting preventive care?
  • How much do we value health equity—or the idea that all of us should have the basics to be as healthy as possible?
  • How much importance do we place on “social solidarity”—or the idea that the needs of others are as important as our own needs?
  • How do we view health care disparities—or how easy or difficult it may be for minority and low-income populations to receive quality health care?
  • How do social determinants such as education, housing, and income impact health?
  • Should the government or the private sector (or both) shoulder the responsibility for making our communities healthier places to live?
  • How do we view our “collective efficacy”—or our ability to work together to improve health in our communities?
  • How do we value civic engagement, or addressing health issues through charities, nonprofits, and voting?

The data from this large national survey were used to create a typology of the American public, reflecting a wide range and diversity of values and beliefs toward health. Six groups emerged from this analysis:

Health Egalitarians (23% of U.S. adults) do not place as much importance at the individual level on personal health as other Americans, and they are less likely to put health first in their daily lives. At the societal level, they are more likely to strongly embrace health equity, but less likely to believe that disparities for different populations exist, or that social determinants influence health. Health Egalitarians also believe government should generally be doing more to promote health, and are more likely than others to believe that building healthier communities is a high priority.

Equity Advocates (16%) are less likely to be highly engaged in personal health—whether through prevention, care seeking, or prayer/meditation. At the societal level, they are more likely to be strongly concerned about equality of opportunity, social solidarity, and health equity. Equity Advocates broadly agree about the existence of disparities, but are less likely to believe that social determinants influence health. They are highly trusting of science and the health care system, and more likely to believe that government generally should do more to promote health.

Committed Activists (18%) are very engaged in their personal health. The majority put health first in daily life, whether through disease prevention, seeking care, frequent prayer or meditation, or openness to alternative medicine. At the societal level, Committed Activists are more likely to believe that health care disparities exist and that the social determinants of health, as well as “non-social determinants” like stress, air and water quality, care access and genetic inheritance, play a role in influencing health. They overwhelmingly believe that health should be a top federal priority.

Self-Reliant Individualists (12%) are very likely to put health first in their daily lives. They are also the most likely of the groups to believe that ordinary people can decide for themselves “what is true” without the need for experts. At the societal level, Self-Reliant Individualists are much less likely to strongly believe in equality of opportunity to succeed, social solidarity, and health equity—or to believe race/ethnic and income-based disparities exist. They are less likely to believe that health should be a top priority for government, but are more likely to be civically engaged through charities or voting based on health issues.

Disinterested Skeptics (17%) do not place high importance on personal health, and are the least health-conscious of the segments. At the societal level, they are less likely to believe in equality of opportunity to succeed, that disparities exist, or that social and non-social determinants have a very strong influence on health. Disinterested Skeptics are much less likely to believe that government should do more to promote health at the federal or community level, and are less likely to be civically engaged.

Private-Sector Champions (14%) are more likely to be oriented toward prevention and seeking care at the personal level, and are much more likely to pray or meditate. They have the least trust in science and the health care system, and often place trust in the wisdom of ordinary people. At the societal level, Private-Sector Champions are less likely to believe that health care disparities exist, but overwhelmingly more likely to believe that social and non-social determinants are important influencers of health. They are the most likely to believe that the private sector should influence health in communities, while less likely to view a role for government.

See the original article.

Read the full report.


Drop In Sudden Cardiac Arrests Linked To Obamacare

The following excerpt comes from an article by Jenny Gold on Kaiser Health News.

If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.

“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.

A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.

The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15 after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.

Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.

Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest] because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.

The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.

“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t, you might let it go for a while,” said Chugh.

Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.

Read the full article.

CAB Member Profile: Rev. Roy Powell

Powell Edited
Rev. Roy Powell speaking at a CAB meeting.

The Sentinel Surveillance to Monitor Progress toward Health Equity project aims to develop and implement a surveillance system to capture the information necessary to monitor progress towards health equity for health disparate populations. One key element of this project is the engagement of community members through a Community Advisory Board (CAB). Recently, Reverend Roy Powell, a community leader, business owner, and member of the CAB, shared a little about his experiences of participating in a research project for the first time.

Tell us a little bit about yourself and your background.

I was born and reared in the Trinity Gardens community here in Mobile. I graduated high school from what was then Trinity Garden’s High school and went to Grambling on a music scholarship. After graduation, I came home, got married and had my children. Spent my working life at International paper and now own a clothing store on Spring Hill Avenue.

I now live in Crichton just ten blocks from where I was born and I love this community. I enjoy the outdoors so I’m always outside and see what’s happening.  I started planting trees and became known as the tree man. This led to my neighbors asking me to take on leadership in our block association to help make improvements in the community.

How did you become involved with the Community Advisory Board for the Sentinel Surveillance Project?

My introduction to the CAB was through Andrea Hudson [former research assistant with the Sentinel Surveillance Project]. I knew her through my work with the community organization I’m a part of. She also went to high school with my oldest daughter. From that relationship, I learned what the project was about and want to be a part of it.

Why did you decide to become part of the CAB?

As I said, my work in the community motivated me to be a part of the CAB. This is a valuable little community and has a lot of potential. So after getting involved and hearing the goals and seeing the investment in the community, I wanted to be a part of it. The greatest asset in a community is the people. And with this project, I saw concern for the people; a genuine desire to help the community.

Give us a few highlights of your time as a CAB member. Is there any one memory that stands out?

The most interesting experience was the Community Campus Partnership conference held in New Orleans in 2016. Our team went to present the experience and represent the larger community. People at that conference were from all over the United States and Canada. Their response was very encouraging. They were interested in what we were doing even though they had their own projects and work.

What community needs are you most concerned about?

Health needs. I’m avid about health. I run across so many people — some who are not as old as I am –whose health is not up to par. And, people are the most valuable part of a community. It’s not the buildings or anything else. It’s the people. So, health awareness is probably the greatest need.

How do you see the sentinel surveillance project addressing these issues in the community?

I believe knowledge is power. I know that’s an old adage but it’s true. I believe that knowing better will help the community do better. Just make a few people aware and maybe we can get people living better health wise. Once the research is presented, it can’t help but make a difference.

My hope is that by sharing this information young people will take notice and advocate in their homes, schools in the environment to do better.

Have you ever been involved in research before, if so how is this similar or different?

No. This is my first experience with research.

What have you learned about research through this process?

I learned you can determine the needs of people in the community by simply asking. It usually takes effort for people to get the assistance but if they are not aware of what’s available they can never get it. I didn’t know how we could reach the population in this community but this research really can help when it’s disseminated.

Has the experience changed the way you consider or approach research in other areas of your life?

I haven’t seen research as a part of life. I never realized how great a part research could play in meeting the needs of the community.  Before, I always considered research to be pointless. But now I see that the information gained will help be beneficial.

Would you encourage others people in your life to participate in or be a part of leading/shaping research projects as a result of your involvement with Sentinel Surveillance?

I would definitely. It has been a source of enlightenment for me.  I just want to encourage the group to keep working and press forward.

CAB Member Profile: Mr. John Jones

The Sentinel Surveillance to Monitor Progress toward Health Equity project aims to develop and implement a surveillance system to capture the information necessary to monitor progress towards health equity for health disparate populations. One key element of this project is the engagement of community members through a Community Advisory Board (CAB).  Recently, Mr. John Jones, a member of the Trinity Gardens community and a member of the CAB, shared a little about his experiences with the CAB.

Tell us a little bit about yourself and your background.

I was born in Chatom, AL, but moved to Mobile in 1947. I first moved to Trinity Gardens in 1949. After high school, I spent four years in the Air Force. Living in South Dakota, I attended the School of Mines in Rapid City. After leaving the Air Force, I returned to Trinity Gardens, graduated from Bishop State.  I spent the next 28 years working for the railroad. I’m now retired and have time to do more in the community.

How did you become involved with the Community Advisory Board for the Sentinel Surveillance Project?

My pastor, Rev. Ulmer Marshall at Trinity Lutheran Church, was involved with the group. He had to step back from the commitment and asked me if I would attend in his place. I came to check it out. I wanted to see if it was something that I could really contribute to. I thought it was worthwhile so became a part of the group.

Why did you decide to become part of the CAB?

I wanted to share my life experience with the community and with the CAB. If I could contribute to something that would help someone improve their health, I wanted to do that.

Give us a few highlights of your time as a CAB member. Is there any one memory that stands out?

I would say the surveys that were taken. Particularly, I was instrumental in going to places and talking with business owners about the project about allowing the team to conduct surveys on their property. They were so congenial and open to helping. I was surprised. They will still ask how things are going and how they can help.

I have learned some things from the areas I’ve been in and the people I’ve talked with. I didn’t realize how many people don’t have insurance and don’t see a doctor until an emergency happens. I guess I saw it but didn’t see it.

What community needs are you most concerned about?

I’m mostly concerned about the lack of medical assistance available in my community. This includes a lack of education on illness, how do avoid different illnesses, and how to manage their disease if they to get sick. The lack of [health] education means people don’t take health seriously.

Over my life, I’ve watched people with diabetes who only had a torso when they were buried. Their limbs had been amputated. Also, people don’t know that they can lead a good life with Diabetes. Many think it is a death sentence. I’m seeing younger and younger people who say they have High Blood Pressure. Being retired, I now have the time to pay more attention to my surroundings.

In a project like this, we can see the problems and how people fall through the cracks. This work allows us to create a catch basin.

How do you see the sentinel surveillance project addressing these issues in the community?

Hopefully, improve the areas where the data has been collected. I like to think this project will address the issues. I have been asked how long are you going to collect data, when are you going to do something. If I didn’t believe in it, I wouldn’t be sitting here.

Have you ever been involved in research before, if so how is this similar or different?

No, I had no research experience before participating in this project.

What have you learned about research through this process?

I’ve learned that people are embarrassed to be honest about their health. I’ve learned that we can’t put people on the defensive when we talk to them about these issues and ask questions. I guess I’ve learned humility. I’ve never been known to have much patience. Now, I can look beyond a “fault” and understand how to help.

I’ve learned that some people can’t help themselves because they don’t know how. This has taught me to reach out and help them on their own terms.

Would you encourage others people in your life to participate in or be a part of leading/shaping research projects as a result of your involvement with Sentinel Surveillance?

Yes, I would but I would be cautious. You have to be careful of people who want to make a big name for themselves and are not really focused on helping the community.

Useful Resource: Peer City Tool and 500 Cities Data

The following comes from an article posted on the site Community Commons titled ‘Peer City Tool and 500 Cities Data: Mapping Trends and Challenges Among Peer Cities’.

The Federal Reserve Bank of Chicago (FRBC) recently introduced the Peer City Identification Tool. The tool identifies peer or “sister” cities that are experiencing similar trends and challenges in equity, economics, and resiliency. It’s meant to provide policymakers, community advocates, and practitioners with context on how their city compares to similar cities. However, it does not mean the cities are the same, but simply highlights cities that are experiencing similar trends and challenges.

The tool was born out of a multi-year study by the FRBC to gather economic and social data on post-industrial cities across the Midwest and Northeast. As opposed to simply publishing a report, the FRBC decided to develop a mapping tool. Today, the tool provides city-level data from 300 cities across the country. Cities with available data have a median population of roughly 100,000.

Since it’s a comparison tool, leaders can see how their own assets and liabilities compare to similar cities in their region and across the country, especially among those with similar histories and challenges. Though the cities may have regional or cultural differences, their shared economic and demographic characteristics have important policy implications for decision makers and planners looking for success stories.  It’s a unique opportunity to share and learn best practices for addressing challenges at the community level.

…With the recent release of the 500 Cities Project data, policymakers and advocates now have access to updated city and tract-level data for chronic disease risk factors, health outcomes, and clinical preventive services. It’s a collaboration between the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation, and the CDC Foundation.

The Peer Identification Tool data gives a snapshot on a variety of social and economic factors among peer cities, like economic resiliency. However, to give an even more robust snapshot, 500 Cities data can be used to explore a variety of health conditions and outcomes.

For example, struggling with unemployment, precarious employment, or poverty can be a factor in higher rates of mental health issues. To explore, 500 Cities data can be brought in to compare the percentage of adults with poor mental health among these sister cities who are experiencing poorer social and economic outcomes. It’s important to note that the base city will have different sister cities in each category, though there may be some overlap.

Read the full article.
Explore the Peer City Identification Tool.
Explore the 500 Cities Project.

Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults

The following comes from a Commonwealth Fund summary of research first published in Health Affairs Web.

Low-income adults in Arkansas and Kentucky who obtained coverage under the Affordable Care Act’s Medicaid expansion had better access to primary care and preventive health services, lower out-of-pocket costs, improved medication compliance, and improved self-reported health status than did low-income adults in Texas, which did not expand Medicaid. Among adults with chronic conditions, ACA coverage was associated with better disease management and medication compliance and a significant increase in self-reported health status.

The Issue
Congress is currently weighing the future of the Affordable Care Act. Since becoming law, the ACA has helped more than 20 million Americans enroll in health insurance coverage, and national studies have noted improvements in coverage, consumer satisfaction, and access to care. In this Commonwealth Fund–supported study, researchers compared Kentucky, which expanded Medicaid as prescribed by the ACA; Arkansas, which obtained a waiver to use federal Medicaid funds available through the ACA to purchase private marketplace insurance for low-income adults; and Texas, which did not expand Medicaid coverage. Looking at these three states, the authors assessed ongoing changes in health care use and self-reported health among low-income adults, including those with chronic conditions, after three full years of the ACA’s coverage expansions.

Key Findings

  • By the end of 2016, the uninsured rate in Arkansas and Kentucky—the two expansion states—had dropped by more than 20 percentage points compared to Texas, the nonexpansion state. In 2016, the uninsured rate was 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.
  • Low-income adults in Kentucky and Arkansas who gained coverage experienced a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket costs, and a 23-point increase in the share of those who reported they were in “excellent” health.
  • Results were similarly positive for people with chronic illnesses who gained coverage because of the ACA. Low-income patients with diabetes, heart disease, hypertension, and stroke who gained coverage were 56 points more likely to report having regular care for their condition than were chronically ill adults in Texas, 51 points less likely than those in Texas to skip medications because of the cost, and 20 points more likely to report being in excellent health.

See the full summary.
See the original article.


Medical Research: Ensuring the Infrastructure of Hope


The following article originally appeared in the Med School Watercooler from the University of South Alabama College of Medicine.

By Selwyn M. Vickers, M.D., FACS; John V. Marymont, M.D., MBA; and Richard M. Myers, Ph.D.

Author information: Vickers, University of Alabama at Birmingham senior vice president of Medicine and dean of the School of Medicine, is a world-renowned surgeon, pancreatic cancer researcher and pioneer in health disparities research. Marymont, University of South Alabama vice president for medical affairs and dean of the College of Medicine, is a nationally known academic leader and orthopaedic surgeon. Myers, HudsonAlpha Institute for Biotechnology president and science director, is an internationally renowned genomics and genetics researcher who was a key contributor to the Human Genome Project.

Medical research means hope for millions of Americans and their families affected by a life-changing disease like Alzheimer’s, diabetes, cancer or heart disease — diseases that certainly have an impact in Alabama. As we look to the future, it is important for Congress to continue to fund the National Institutes of Health to provide for the critical infrastructure needed by our nation’s medical research enterprise.

Today, the physicians, scientists and patients at the UAB School of Medicine, USA College of Medicine and HudsonAlpha Institute for Biotechnology urge Congress to continue its commitment to sustained, robust growth in the NIH by creating a sustainable model for funding the NIH moving forward. Congress responded in a bipartisan and positive way to the extreme cuts proposed by the administration. Investment in scientific discovery is crucial to improve the health of patients, strengthen the economy in the near and long terms, and maintain the United States’ global pre-eminence in medical innovation.

The nation invests less than $100 per person annually for all of the research conducted and supported by the NIH, yet the return on investment has been spectacular for us all. The quality of life for millions of Americans has been improved by innovations in treatment, technology and care resulting from NIH-supported research across the country.

Because of NIH-funded research, the HIV transmission rate in the United States from infected mothers to their babies has fallen from 27 percent in 1990 to less than 1 percent in 2017. Childhood cancer patients with lymphocytic leukemia now have a five-year survival rate of 90 percent as a result of available treatments. People battling high cholesterol can take statins to manage their health. Vaccines have been developed to prevent hepatitis A, rotavirus and the human papillomavirus (HPV). The emerging field of genomics is the foundation for countless discoveries. While there is tremendous potential, advances in genomics have identified key factors in widespread, costly diseases such as Alzheimer’s and have provided prevention strategies for breast and other cancers.

The federal government, primarily through NIH, plays an irreplaceable role in supporting medical innovations by funding the research that serves as the foundation for these and other lifesaving advances. Given the uncertainty of discovery — the next important insight into a disease could come from a number of different avenues or organisms — industry relies on this investment to inform our fundamental understanding of medicine. This research is a springboard that speeds and makes possible the development of treatments and cures.

Physicians and scientists at U.S. medical schools and teaching hospitals such as the UAB and USA Schools of Medicine conduct more than half of all external research funded by NIH. Because of NIH support, these investigators are a force for translational discovery through their ongoing research of techniques such as deep brain stimulation, an important treatment for patients with Parkinson’s disease and other movement disorders; exploration of molecular changes that happen to the body during and after exercise; and design of cutting-edge clinical trials to advance discovery and new therapies.

The proposed cuts to NIH funding not only affect medical research, but they affect the very fabric of academic medical centers and nonprofit research institutes— institutions across the country employing faculty and staff to conduct this scientific research and provide the best possible care for patients. At UAB, USA and HudsonAlpha, less than 15 percent of funding comes from the state of Alabama. More than 25 percent of revenue comes from federal grants, including those from the NIH and U.S. Department of Health and Human Services. Removing or reducing that funding would be devastating for patients, researchers and works alike.

Forty-five of the nation’s 50 states have academic medical centers, each making large economic impacts, both in  its local and regional communities and in its state as a whole. UAB and USA are among the largest employers in Alabama.  

This kind of economic development has made the United States the world leader in medical research, but its stature may be slipping as other countries have been increasing their public investment in research. While Congress recently took important steps to help the NIH regain some of its lost purchasing power, flat — or even worse, reduced — future appropriations threaten to undermine these key efforts. Because research cannot be turned on and off like a spigot, there must be sustained and predictable NIH budget growth so that researchers can build on previous progress and investment.

Millions of Americans depend on medical research to provide hope in the face of potentially devastating diagnoses. The UAB and USA Schools of Medicine, HudsonAlpha, and the nation’s medical schools, teaching hospitals and nonprofit research institutions urge Congress to help us to maintain the infrastructure of hope.

Our patients — and all Americans — deserve it.