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.


Synopsis
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.

 

Medicaid’s Role in Providing Access to Preventive Care for Adults

The following excerpt is from a Data Note by Leighton Ku, Julia Paradise, and Victoria Thompson published by the Kaiser Family Foundation published on May 17, 2017.


Medicaid, the nation’s public health insurance program for people with low income, covers 74 million Americans today, including millions of low-income adults. The Affordable Care Act (ACA) expanded Medicaid to nonelderly adults with income up to 138% of the federal poverty level (FPL), and, in the 32 states (including DC) that implemented the expansion, more than 11 million adults have gained Medicaid as a result. Chronic illness is prevalent in the adult Medicaid population. Preventive care, including immunizations and regular screenings that permit early detection and treatment of chronic conditions, improves the prospects for better health outcomes. This Data Note focuses on Medicaid’s role in providing access to preventive care for low-income adults.

Why is preventive care for adult Medicaid Enrollees Important?

Adults in Medicaid have high rates of preventable and controllable conditions. Nearly one-third (30%) of non-elderly adult Medicaid beneficiaries report that they are in only fair or poor health – roughly double the percentage of low-income privately insured and uninsured adults who report fair or poor  health (Figure 1). Medicaid adults also have significantly higher rates of chronic conditions and risky health behaviors that may be amenable to preventive care. One in 10 adult enrollees has a diagnosed mental illness; 7 in 10 are overweight or obese, and almost 1 in 3 smoke tobacco.

Preventive care can reduce disease and avoidable use of high-cost services. Increased access to screening for diabetes, cancer, depression, and o ther chronic conditions, and counseling to address behavioral risk factors, have the potential to reduce disease and prevent exacerbations of conditions that can be medically managed. Improved health may reduce the use of avoidable hospital and other high-cost care, and reduce Medicaid spending. For example, smoking can cause heart disease and other chronic illnesses that one study estimated may be responsible for more than $75 billion in Medicaid costs. Medicaid coverage of smoking cessation services, including quit lines and medications, has the potential to mitigate both the health and cost impacts of smoking. Obesity, a major driver of preventable chronic illness and health care costs, affects about two-thirds of low-income adults. Findings from one study indicate that severe obesity in adults cost state Medicaid programs almost $8 billion in 2013, suggesting that “effective treatment for severe obesity should be part of each state’s strategy to mitigate rising obesity-related costs.”

What Preventive Services Does Medicaid Cover for Adults?

Coverage of most adult preventive services has historically been optional for states. Medicaid coverage of preventive services for children has long been strong, as states must cover comprehensive preventive services at no cost for children in Medicaid under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. In contrast, historically, coverage of adult preventive care has been largely optional for states, with some exceptions – states must cover pregnancy-related care and family planning services without cost-sharing. In addition, within federal guidelines, states can charge adults cost-sharing for preventive services.

The ACA expanded coverage of adult preventive care. An important thrust of the ACA was an emphasis on preventive care. In particular, the ACA included recommended preventive services without patient cost-sharing as one of the 10 “essential health benefits” (EHBs) that most health plans are now required to cover. The required preventive services are based on the recommendations of independent, expert clinical panels and include, for adults: 1) screening and counseling services (e.g., cancer screening, diet counseling); 2) routine immunizations; and 3) preventive services for women. The EHB requirement applies to Medicaid benefits for adults who are newly eligible due to the ACA expansion, but not “traditional” Medicaid adults, for whom most preventive services are optional for states and can require cost-sharing within federal guidelines. To incentivize states to cover the EHB preventive services for all Medicaid adults, the ACA provided for a one percentage point increase in the federal Medicaid match rate for these services in states that opt to cover all of them without cost-sharing.

Read the full data note.

 

‘Connectivity’ as the Key to Healthy Communities

The following excerpt originally appeared in in an article by Shannon Firth in MedPage Today  on May 11, 2017 summarizing a panel discussion that had taken place on May 9, 2017.


Keeping people connected to resources necessary to maintain good health — not least of which is other people — is a vital but often neglected factor in modern healthcare, policy experts and scholars said here Tuesday.

Transportation is an “underappreciated” health problem, said Dayna Bowen Matthew, JD, a nonresident senior fellow at the Brookings Center for Health Policy, at a panel discussion hosted by the Brookings Institution on Tuesday.

She noted that interstate highways aren’t always a means of connecting people to each other and to resources: in cities, they create barriers as well.

A grid of superhighways can mean a person living in a city’s southeast quadrant must take two buses and time off from work to reach a well-intentioned “food solution” in the northwest quadrant.

“That community’s not connected,” said Bowen Matthew, who is also a professor at University of Colorado Law School and the Colorado School of Public Health, and author of Just Medicine: A Cure for Racial Inequality in American Health Care.

Those families across town from farmers’ markets and other fresh food resources will rely on the more accessible options instead, which may be fast food.

Tuesday’s discussion focused heavily on the social determinants of health — nonmedical factors that greatly influence a population’s health such as transportation, housing, access to food — but one thing unites these influences: connectivity.

Social Networks are Key

The National Health Service in England has a “district nurse,” an individual responsible for keeping watch over certain neighborhoods, explained, Stuart Butler, PhD, a senior fellow in economics for the Brookings Institution.

Growing up in England, Butler’s mother ran a post office, which was a key source of “intel” for the district nurse on the community residents’ well-being. If Butler’s mother hadn’t seen someone for a few days, the nurse would learn of this and ride her bicycle to the person’s home.

Decades later and an ocean away, Matt Brown, RN, a geriatric nurse navigator at Sibley Memorial Hospital in Washington, learned quickly about the importance of follow-up phone calls to ensure smooth transitions back to the community.

During his first such call as part of a senior-focused transition project, he spoke to a patient who had just returned home after being hospitalized for pneumonia.

In the course of the phone call, the patient reluctantly admitted he had fallen and couldn’t get up off the floor of his home. Brown convinced him to call 911, rather than wait for the patient’s wife to come home. When the ambulance arrived, Brown spoke with the emergency medical technicians to confirm his patient was okay.

To further reduce the risk of injuries, the Sibley Innovation Hub has offered a short training course focused on transitions after certain surgeries, which they are now supplementing with animated patient education videos.

Read the full article.

Segregated Living Linked To Higher Blood Pressure Among Blacks

The following article by Carmen Heredia Rodriguez originally appeared on Kaiser Health News.


For African-Americans, the isolation of living in a racially segregated neighborhood may lead to an important health issue: higher blood pressure.

A study published Monday in JAMA Internal Medicine suggested blacks living in such areas experienced higher blood pressure than those living in more diverse communities. Moving to integrated areas was associated with a decrease in blood pressure, and those who permanently stayed in localities with low segregation saw their pressure fall on average nearly 6 points.

Kiarri Kershaw, assistant professor of preventive medicine at Northwestern University in Chicago and lead author of the study, said the findings reinforce the close relationship between social policy and community health outcomes.

“It lends credence to the notion that we should bring public health practitioners and health policy officials to the table to make these decisions,” she said. Researchers used data from a long-term study that has followed 2,280 African-Americans over the course of 25 years, checking in every three to seven years to track blood pressure.

Heart disease is the leading cause of death in the United States, and African-Americans are disproportionately affected by the condition. According to the American Heart Association, 46 percent of non-Hispanic black men and nearly 48 percent of non-Hispanic black women live with a form of heart disease, while about 36 percent of non-Hispanic white men and 32 percent of non-Hispanic white women do.

Georges Benjamin, executive director of the American Public Health Association, said the burden to address such disparities falls on society at large.

“It doesn’t just hurt African-Americans or people of color. This hurts everybody,” he said. “Because everyone pays not just in terms of humanity, but in terms of dollars.”

Doctors generally record two numbers for blood pressure: the diastolic pressure — the blood’s force inside the veins when the heart is at rest — and the systolic pressure, which gauges the blood’s force when the heart beats. Blood pressure is measured in millimeters of mercury, or mmHg (using mercury’s chemical element symbol), with systolic pressure reported first, such as 115 mmHg over 75 mmHg.

Researchers found residential segregation was associated with changes in systolic blood pressure, which is tied to adverse cardiovascular events, such as a heart attack. The findings did not show any changes in diastolic blood pressure.

The scientists also collected data on a variety of other social indicators including level of education, poverty and marriage status. They ranked the level of segregation in participants’ neighborhoods as “low,” “medium” and “high” based on the number of African-Americans in the larger area.

When compared to African-Americans living in highly segregated locations, participants living in medium-segregation neighborhoods recorded blood pressure that was on average 1.33 mmHg lower. Those residing in low-segregation areas were an average 1.19 mmHg lower.

Blood pressure for black residents who permanently moved into medium segregation locations decreased on average 3.94 mmHg. African-Americans who stayed in low-segregation locales saw an average decrease of 5.71 mmHg.

Read the full article.

HDRG Recap: Health Care Apartheid: Labor Markets, Race-Ethnicity, and Affordable Care

At the April 21, 2017, meeting of the Health Disparities Research Group (HDRG), Dr. Kenneth Hudson and his team presented findings from their research on the impact of the Patient Protection and Affordable Care Act (ACA) on insurance rates. This work is part of the research project The Impact of Labor Force/Labor Market  Status on Access to Health Care. The presentation focused on analysis of data from the  Current Population Survey (CPS).

Dr. Hudson began his talk by outlining the theoretical foundations of and major influences on his work. Citing the work of Dr. William Julius Wilson on race and labor markets and the work of Clayton and Byrd on the history of minority health disparities, Dr. Hudson outlined three eras in American history focusing on race and labor relations, and the provision of medical care. After the civil rights movement, institutions  such as hospitals couldn’t overtly discriminate on race, but they could, however, discriminate based on the ability to pay. Currently, the primary mechanism for covering the cost of health care in the United States is health insurance, which is usually provided by either an employer, family members, or a government program such as Medicare or Medicaid.

Within this context, Dr. Hudson relayed the findings from his team’s analysis of the health insurance data from the CPS. The findings reaffirmed what was already known; the ACA substantially reduced the rate of uninsured Americans. They also found that the expansion of Medicaid was the primary mechanism for this reduction, even though 19 states chose not to participate in the Medicaid expansion program..

Dr. Hudson and his team are currently preparing their findings for publication.

Malnutrition and Minority Older Adults: A Health Equity Issue

From the article by Bob Blancato on HuffPost:

Any discussion of minority populations in America must include the rapid increase in the percentage of minorities in the older adult population. The 2016 Profile of Older Americanscontains some specific examples of the minority population growth. Racial and ethnic older adult minority populations have increased from 6.7 million people (18% of all older adults) in 2005 to 10.6 million in 2015 (22% of older adults) and will more than double to 21.1 million in 2030 (28% of older adults). African-Americans and Hispanics comprised the largest share of minority groups in 2015.

These older adults of color are more likely to have chronic health concerns—one significant risk factor for older adult malnutrition. According to the Centers for Disease Control and Prevention (CDC), “blacks are 40% more likely than non-Hispanic whites to have high blood pressure, and they are less likely to have this condition under control.” Also, the rate of diabetes diagnoses is 77% higher among blacks, 66% higher among Hispanics, and 18% higher among Asians than among whites.

Economic factors, including food insecurity, are also linked to malnutrition—and 18.4% of older blacks, 11.8% of older Asians, and 17.5% of older Hispanics were below the poverty level in 2015, compared to just 6.6% of white older adults, according to the Profile. Further, white older adults have food insecurity rates that are less than half the rates for black seniors, and similarly, Hispanic older adults have food insecurity rates which are more than double the rates of non-Hispanic older adults.

These startling numbers add up to a picture of health disparities in minority healthcare. Because of this, malnutrition care must be a part of health screenings for every older adult in every care setting, with an emphasis on reaching all populations. As the Congressional Black Caucus Institute in their 21st Century Council 2015 Annual Report noted, “The most benefit will occur when malnutrition care becomes a priority and routine standard of medical care.”

Malnutrition is a serious concern for older adults. The cost of disease-associated malnutrition in older adults in the U.S. is estimated to be $51.3 billion per year, and up to one out of two older adults are at risk of becoming malnourished, according to the newly-released National Blueprint: Achieving Quality Malnutrition Care for Older Adults.

Read the full article.

Medicaid Helps Schools Help Children

From the report by Jessica Schubel on the Center on Budget and Policy Priorities website:

Medicaid provides affordable and comprehensive health coverage to over 30 million children, improving their health and their families’ financial well-being.[1] In addition to the immediate health and financial benefits that Medicaid provides, children covered by Medicaid experience long-term health and economic gains as adults.[2] Many children receive Medicaid-covered health care not only at the doctor’s office, but also often at school.

For students with disabilities, schools must provide medical services that are necessary for them to get an education as part of their special education plans, and Medicaid pays for these services for eligible children. And Medicaid’s role in schools goes beyond special education, as it also pays for health services that all children need, such as vision and dental screenings, when they are provided in schools to Medicaid-eligible children. Schools can also help enroll eligible but unenrolled children in Medicaid or the Children’s Health Insurance Program (CHIP), and connect them to other health care services and providers. Medicaid also helps schools by reducing special education and other healthcare-related costs, freeing up funding in state and school budgets to help advance other education initiatives.

Read the full report to learn more about

  • Leveraging Medicaid for special education
  • Helping kids stay healthy and succeed academically
  • Connecting kids to coverage

As Some Holdout States Revisit Medicaid Expansion, New Data Show It Pays Off

From the article by Shefali Luthra on Kaiser Health News:

Although the GOP-controlled Congress is pledging its continued interest — despite stalls and snags — to dismantle Obamacare, some “red state” legislatures are changing course and showing a newfound interest in embracing the health law’s Medicaid expansion.

And a study out Wednesday in Health Affairs adds to these discussions, percolating in places such as Kansas, Georgia, Virginia, North Carolina and Maine. Thirty-one states plus the District of Columbia already opted to pursue the expansion, which provided federal funding to broaden eligibility to include most low-income adults with incomes up to 138 percent of the federal poverty level (about $16,000 for an individual).

Researchers analyzed data from the National Association of State Budget Officers for fiscal years 2010 to 2015 to assess the fiscal effects of expansion’s first two years.

Their findings address arguments put forth by some GOP lawmakers, who say the expansion will add to the nation’s budget deficit and saddle states with additional coverage costs, forcing them to skimp on other budget priorities like education or transportation.

The researchers concluded that when states expanded eligibility for the low-income health insurance program they did see larger health care expenditures — but those costs were covered with federal funding. In addition, expansion states didn’t have to skimp on other policy priorities — such as environment, housing and other public health initiatives — to make ends meet.

“This is a potential big benefit, not only to people who get coverage, but to state economies,” said Benjamin Sommers, an associate professor of health policy and economics at Harvard University’s public health school, and the study’s first author.

This finding — that states expanding Medicaid didn’t encounter unforeseen budget problems — shouldn’t be surprising.

“Expansion is basically free” to the states, agreed Massachusetts Institute of Technology economist Jonathan Gruber, one of Obamacare’s architects who worked with Sommers to systematically compare the budgets of all 50 states to examine Medicaid expansion’s impact. “That’s the big insight,” he said. “There’s no sort of hidden downside.”

And that may be part of what’s fueling this renewed interest, said Edwin Park, vice president for health policy at the left-leaning Center for Budget and Policy Priorities. These states are seeing the federal windfall their neighbors received while trying to navigate public health concerns like opioid addiction, he said. They “are looking at how their neighbors or expansion states have done, and see the benefits,” Park said. “The primary argument against the expansion on the state level has been it’s going to break the bank. The research demonstrates that’s not the case.”

But a caveat: The data used in this analysis reflected only years during which the federal government picked up 100 percent of the tab for expanding Medicaid eligibility and therefore could overestimate the benefit to state budgets. That’s because in 2017 that federal support begins to taper off, and by 2020 states have to pay 10 percent of the expansion costs themselves.

Read the full article.

Workers Who Give Care To The Homebound Often Can’t Afford To Get Their Own

From the article by Shefali Luthra on Kaiser Health News:

For more than two decades, Celeste Thompson, 57, a home care worker in Missoula, Mont., had not had regular contact with a doctor — no annual physicals and limited sick visits. She also needed new glasses.

Like many others who work in the lower rungs of the health care system, she has worked hard to keep her clients healthy by feeding them, dressing them and helping them navigate chronic conditions.

But because of the low wages and the hourly structure of this industry — which analysts estimate is worth nearly $100 billion annually and projected to grow rapidly — workers like Thompson often don’t have health insurance. Many home health agencies, 80 percent of which are for-profit, don’t offer coverage, or their employees don’t consistently clock enough hours to be eligible. They generally earn too much to qualify for public aid but too little to afford the cost of premiums.

“It’s a social justice issue. We have a workforce that is the backbone of long-term [care] services, and they themselves don’t have coverage,” said Caitlin Connolly, who runs a campaign to increase home care wages at the National Employment Law Project, an advocacy organization.

In 2015, Montana opted in to the 2010 health law’s expansion of Medicaid, the state-federal low-income health insurance program. Thompson, who was making about $10 an hour, immediately signed up.

Her vision care was among the first things she focused on. She had not visited an eye doctor in nine years — a problem because her job includes keeping track of patients’ pill bottles and making sure they take the right medications. “I had to use a magnifying glass to see small print,” said Thompson, who now wears bifocals. Her doctor has since warned her she may need a stronger correction soon.

…Thompson is part of a large population of home-based caregivers who might be affected by such changes. From 2010 to 2014, about half a million of these workers gained new health insurance through Obamacare, estimates PHI, a New York-based nonprofit that researches this slice of the labor force and advocates for improved working conditions, in a March issue brief.

Most home care workers’ gains came from living in states that, like Montana, expanded Medicaid. But even with Obamacare in place, many home health workers — perhaps 1 in 5 — remain uninsured. By contrast, about 8.6 percent of all Americans lack coverage.

Read the full article.

Talking About Equity: Promoting the Curb-Cut Effect

From the Annie E. Casey Foundation Blog:

In a recent Stanford Social Innovation Review article, Angela Glover Blackwell shows how developing policies to create equity can improve everyone’s lives. She does it with a simple example: curb cuts.

Glover Blackwell, CEO and cofonder of PolicyLink, a grantee within Casey’s equity and inclusion portfolio, cites the push by citizens with disabilities and advocates in the late 1970s to make communities more accessible for wheelchairs. When the federal Americans with Disabilities Act required that curb cuts and sidewalk ramps be installed everywhere, the new accessibility didn’t just make a difference for the disability community. The curb cuts and ramps created a new way for mothers with strollers, cyclists, delivery workers, scooter riders, kids on bicycles and just about every pedestrian to travel streets more safely and easily. The Casey Foundation believes the same principles can be applied to improving outcomes for children in the United States.

“Creating policy that is explicit about eliminating an inequity around race or ethnicity is one of the most effective paths to creating better opportunities and outcomes for all children, not just one group,” says Nonet Sykes, director of racial and ethnic equity and inclusion at Casey. “Using tools, such as the Racial Equity Impact Assessment, can help leaders fine-tune pieces of legislation for targeted investment.”

Glover Blackwell cites other policies that have had similar results — such as seat belt laws and the G.I. Bill of the 1940s — as further evidence of the curb-cut effect.

She writes that applying curb-cut thinking to transportation infrastructure or employment policy would significantly boost the GDP of the country’s 150 largest metropolitan regions. Further, she notes, policies to create equitable opportunities for children of color could strengthen our economy for generations, especially since children of color will soon comprise the majority of kids in the United States.

 

Read the full article.