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.

Upcoming HDRG Meetings

The Health Disparities Research Group (HDRG) is a multidisciplinary assembly of faculty, students, staff, and community representatives with a vision “to become an integral facilitator in eliminating health disparities through partnerships with our community.” Held the 3rd Friday of each month throughout the academic year, the meetings provide an opportunity to share research and cultivate a positive atmosphere for community-engagement in addressing health disparities.

The next meeting is April 21 at 1:00 pm in Bio-medical Library Room 222-A. Dr. C. Kenneth Hudson will provide an update on the project “The Impact of Labor Force/Labor Market Status On Access To Health Care”.

In May, Dr. Erick Goldschmidt, Director of the Spring Hill College Foley Center for Community Service, will share about their work.

 

When Housing Comes First, Hospitals Benefit

From the article by Lola Butcher on Hospitals & Health Networks:

Supportive housing is a multifaceted model to help homeless individuals and families that face complex challenges such as addiction, mental health conditions and disabilities that can be overwhelming. In addition to permanent housing, the model provides social services that range from substance abuse programs and life skills training to case management and job training.

Many, but not all, supportive housing programs use the “housing first” approach, endorsed by the federal government. Under “housing first,” permanent housing should be made the top priority for homeless individuals and families; addressing behavioral, social and other factors comes second.

The peace of mind that comes from a safe place to live helps individuals as they tackle addiction or other challenges. Plus, service providers know where to contact the individuals to provide the help they need.

“If you provide housing stability first and then provide the wraparound supports, people are much more successful,” says Shannon Nazworth, executive director of Ability Housing, a nonprofit organization that provides supportive housing in parts of Florida.

Ability recently received a grant from the Florida Blue Foundation, a philanthropic foundation affiliated with the state’s Blue Cross and Blue Shield health plan. The grant supports a statewide pilot project to study how permanent supportive housing affects the health and quality of life of high utilizers of crisis services — and how it affects their use of health care and other publicly funded support services.

A growing body of research, in fact, suggests that the benefits of housing programs for the health care system might be substantial. Researchers at Yale University’s Global Health Leadership Institute evaluated and summarized the results of several studies in the area in their report “Leveraging the Social Determinants of Health: What Works?” (Lauren A. Taylor et al., Blue Cross Blue Shield of Massachusetts Foundation, 2015):

  • A “housing first” program in Seattle found that the median per person, per month cost of incarceration, emergency medical services, hospital-based medical services, detoxification and other publicly funded programs fell from $4,066 to $958 after 12 months in housing. This added up to annual net savings — after accounting for housing costs — of $29,388 per person compared with a control group.
  • A Massachusetts initiative that targeted homeless people with serious mental illness reduced the average number of hospital days per client from 102 to seven within two years after housing placement. That reduced hospital costs by about $18 million per year overall.
  • A Los Angeles program that serves homeless patients with the highest public services and hospital costs documented that every $1 invested in housing and support reduced public and hospital costs by $2 the following year and $6 in subsequent years.

Read the full article.

 

Repealing Federal Health Reform: Economic and Employment Consequences for States

From the issue brief published by The Commonwealth Fund:

…Recent analyses show canceling the ACA’s tax credits and Medicaid expansion would double the number of uninsured Americans.2,3 As millions lose their insurance, hospitals and other providers would see their uncompensated medical care costs soar by $1.1 trillion from 2019 to 2028, and they would experience major revenue losses as well.

But repeal could also have much broader economic repercussions. Our analysis examines the potential economic and employment effects of repealing the ACA’s tax credits and Medicaid expansion, without a replacement plan, for every state and the District of Columbia. We estimate changes in:

  • employment—the number of jobs lost in health care, construction, and other sectors of the economy
  • economic activity, such as state gross product (the state equivalent of national gross domestic product) and business output
  • state and local tax revenues.

…Health care will comprise almost one-fifth (18.5%) of the nation’s economy by 2019.9 As such, major changes to health care will reverberate across other parts of the economy.  Federal tax credits first flow to health insurers. Most of the money, aside from carriers’ overhead, flows to hospitals, clinics, pharmacies, and other providers. Similarly, federal funding supports state Medicaid programs, which pay health care providers. These are the direct effects of federal funding.

Most of the revenue earned by health care providers is used to hire and pay staff and to purchase goods and services, like clinic space or medical equipment. In turn, those vendors pay their employees and buy additional goods and services. This is the indirect effect of federal funding.

The induced effect is manifested as workers use their incomes to pay for food, mortgages, rent, transportation, and other goods and services, which provides income to other businesses.

Federal funding thus initiates an economic cycle that ripples throughout the economy, both within and across state borders. The gains from this cycle also generate additional state and local tax revenues. When federal funds are cut, the results play out in the other direction, triggering losses in employment, economic activity, and state and local revenues.

The potential effects of the repeal of both premium tax credits and Medicaid expansion include:

  • …repeal results in a $140 billion cut in federal funding for health care in 2019. This in turn leads to about 2.6 million jobs lost that year, rising to nearly 3 million by 2021. A third of these lost jobs are in health care, but the majority is in other industries such as construction, real estate, retail trade, and finance. Nearly all are private-sector jobs.
  • …canceling states’ Medicaid expansions lowers federal funding by $466 billion from 2019 to 2023. This leads to 1.5 million fewer people with jobs in 2019. Moreover, gross state products shrink by nearly $900 billion and state and local tax revenues drop by $29 billion.

Read the full issue brief.

Economic Effects of Medicaid Expansion in Michigan

From the post by The Commonwealth Fund:

Background

The debate over whether and how to repeal the Affordable Care Act often focuses on the cost of the Medicaid expansion—an area of concern for some states, which starting this year must assume a portion of the coverage costs for newly eligible enrollees. Less attention is paid to the economic benefit expansion states receive from the influx of federal money, including increased employment and tax revenue. The authors of this Commonwealth Fund–supported study assessed the economic impact of Michigan’s Medicaid expansion. The Healthy Michigan Plan has enrolled roughly 600,000 low-income residents.

What the Study Found

Michigan’s Medicaid expansion will create at least 30,000 jobs in the state each year from 2017 to 2021 and raise personal income by more than $2 billion each year. The added economic activity is projected to yield $145 million to $153 million annually in state tax revenue.

Read the full post from The Commonwealth Fund.

Health Coverage is My Road to Independence

From the article by Mary Leapart on HHS.gov:

I am an educator by profession and at heart. I taught high school for 10 years and then left the classroom to work in curriculum development and training. In the years since leaving the classroom, I realized that I had developed many skills that I could use to start a career as an independent consultant. I had always dreamed of working for myself. The only obstacle in my way was health insurance.

You see, I have bipolar disorder and maintain my health by regularly seeing a therapist and a psychiatrist, taking my meds, and employing other holistic health practices. My only options for insurance after leaving my full-time job was COBRA, the insurance offered to me after I left my job, or finding my own plan. COBRA was going to cost more than $800 a month, so I chose to find my own insurance through private insurers. However, despite the fact that I managed my disorder responsibly, I was turned down by two companies due to my pre-existing condition.

I had to put my dream of working for myself on hold and find a job that provided health insurance. I went without coverage for several months while I was looking for a new position. Without insurance, I was uneasy. I walked around on eggshells, knowing that any injury or illness could be a financial disaster.

After a year in my new full-time job, the Health Insurance Marketplace opened, providing insurance options, despite my pre-existing condition. Initially, I thought the process of shopping for a plan through the Marketplace would be overwhelming, so I stayed at my current job—just for the health insurance.

But then I decided that I didn’t want to wait any longer to chase my dream. At the beginning of 2015, I started my own consulting business. So it was time to get covered. This time, I heard about the Navigator program, where I could get personal help to find and enroll in a Marketplace plan. My assister was great at explaining my options and how to sign up.

My plan went into effect March 1, 2015. My premium was only $50 a month after tax credits. It was wonderful coverage. I had a $0 deductible and my therapist copay was also $0.

The financial assistance I receive under the Affordable Care Act adjusts with my income, so I do pay more for my coverage now since I have started making more money. This year, I returned to the classroom to teach part-time while I work on developing my consulting business. But the coverage has remained available and affordable, and the fact that I can even buy insurance on my own means so much to me. I am always working to be seen as more than just a label—bipolar disorder. Thanks to the Affordable Care Act, this is one less arena where I have to take up that fight.

Because of the Affordable Care Act and the 2008 mental health parity law, I can’t be denied coverage because of my pre-existing bipolar disorder, and I can use my Marketplace coverage to get mental health services along with medical care. The parity law requires insurance plans to treat benefits for mental health and substance use treatment no differently than medical and surgical benefits.

Read the full article.

Why the U.S. Needs Medicaid

From the report by Rachel Nuzum, Sara R. Collins, Melinda K. Abrams, Pamela Riley, M.D., Jordan Kiszla and Jamie Ryan from the Commonwealth Fund:

While most news stories about Medicaid focus on states’ decisions on whether to expand eligibility, the collective impact of the program on beneficiaries, health providers and systems, and state economies is rarely discussed. Given the large share of federal funds devoted to Medicaid, it’s reasonable to assume that policymakers on both sides of the aisle will be considering programmatic or financing changes for the program—or both—early in a new presidential administration. To inform that process, it’s helpful to look at the multifaceted role Medicaid plays in our health system.

When it was signed into law in 1965 as an extension of welfare, few would have anticipated Medicaid would evolve into the nation’s largest health insurer, covering nearly 73 million Americans.1 Today, Medicaid is at the center of the American health care safety net, providing benefits to adults and children otherwise unable to afford care—and helping to support and drive innovation in the hospitals and clinics that treat these patients, as well as supporting state economies.

Medicaid provides people with good insurance. While the program can vary somewhat by state, a growing body of evidence finds that Medicaid provides a comprehensive set of benefits as well as strong financial protections. A 2015 analysis of the Commonwealth Fund Biennial Health Insurance Survey suggests that people with Medicaid coverage have better access to health care services, including proven preventive care, and fewer medically related financial burdens than those who lack insurance. The same study found that Medicaid enrollees have nearly equivalent access to care as those with private coverage in many areas.

Other study findings included:

  • Most adults with Marketplace or Medicaid coverage continue to be satisfied with it
  • 24 state Medicaid programs have active medical home initiatives

Read the full report.

Labor Market Health Care Project

In 2006, Dr. Kenneth Hudson, Associate Professor of Sociology and Social Work, began work on the Labor Market Health Care Project to examine the relationship between employment and health care. The project consists of two parts:

  • The Labor Market Health Care Survey (LMHCS)  focused on a small sample longitudinal study of employment and health care in high poverty neighborhoods in Mobile County.
  • Examination of the Current Population Survey (CPS) data assessing the impact of the Affordable Care Act (ACA) on health insurance coverage in the United States.
labor-force-research-team-edited
Pictured from left to Right: Timothy Linthicum, marcellus Hudson, Kenneth Hudson, Alan Akira, Andrea Hudson, and Errol Crook. Not shown: Marcus Mitchel and Destini Smith

To date, the LMHCS research team has collected data from 230 participants regarding their employment and health care. The employment data includes information about the participant’s jobs over their life course, and whether or not their jobs have provided them with health insurance.  We have also collected information about the participant’s health care provider and the health care services they receive.

We find that many of our participants have jobs that do not provide them with health insurance. Those that have employer provided health insurance frequently do not have it over their life course. This reality is important considering that health insurance coverage and having a personal relationship with a medical doctor is a key predictor of whether or not the diagnostic testing for diabetes and heart disease.

The second component of the project, our analysis of data from the CPS, shows that the ACA has greatly reduced the proportion of adult Americans without health insurance. Most of the reduction has resulted from the expansion of the Medicaid program.

Publications and presentations resulting from the project include:

Publications

Linthicum, Timothy. 2015. “ Health Insurance in America: Who Has it and How They Got it.” M.A. thesis, Department of Sociology, Anthropology, and Social Work, University of South Alabama, Mobile, AL.

Bryan, Valerie, Willette Brye, Kenneth Hudson, Leevones Fisher, Shantisha Hansberry, and Martha Arrietta. 2014. “Investigating Health Disparities through Community-Based Participatory Research: Lessons Learned from a Process Evaluation.” Social Work in Public Health 29:318-334.

Hudson, Kenneth. 2013 “Labor Markets.” In Vicki Smith (Ed.), Volume 1 of Sociology of Work: An Encyclopedia. Sage.

Conference Presentations

Hudson, Kenneth, Andrea Hudson, and Marcellus Hudson. 2016. “The Labor Market Health Care Survey: Using Probability Sampling with Microdata.” Paper presented at the 2016 Meeting of the Southern Sociological Society in Atlanta, GA.

Hudson, Kenneth, 2015. “Labor Market Segmentation, Race, and Health Insurance Coverage.” Paper presented at the 2015 Meeting of the American Sociological Society in Chicago, IL.

Akira, Alan, 2015 “Measuring Health Care Utilization in Low Income Communities.” Paper presented at the Southern Regional Meeting of the American Federation for Medical Research, New Orleans, LA.

Hudson, Kenneth. 2012. “Dual Labor Market Theory and Its Unanswered Question.” Paper presented at the Institute for Work and Employment Research Seminar, Massachusetts Institute of Technology Sloan School of Management, Cambridge, MA. May 1.

Hudson, Kenneth. 2010. “How Do You Do It? Methodological Questions, Challenges, and Ideas in Researching Health Disparities. ”Paper presented at 2010 Meeting of the Mid-South Sociological Association in Baton Rouge, LA.

Hudson, Kenneth. 2010 Session Organizer, Methodology and Health Disparities. at 2010 Meeting of the Mid-South Sociological Association in Baton Rouge, LA.

Hudson, Kenneth, Shermeka Hawthorne, Martha Arrieta, and Errol Crook. 2010. “The Impact of Labor Market Segmentation on Health Care in Low-Income Neighborhoods.” Paper presented at the 2010 Meeting of the Southern Sociological Society in Atlanta, GA.

 

Attending To The ‘Human Element’ Is Key To Keeping Patients Healthy

From the article by Shefali Luthra on Kaiser Health News:

Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care’s black boxes. Forthcoming research may help shed light on what’s driving those inequities — and how the system can fix them.

What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers’ health decisions.

Those ideas were highlighted in a white paper presented recently at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 “disadvantaged patients,” along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.

The paper suggests that “implicit bias” — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients’ perception of it could have consequences for people’s health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.

“We for a long time have neglected the human element,” said Chris Duke, director of Altarum’s Center for Consumer Choice in Health Care, and the white paper’s author. “The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril.”

Duke stressed that the research isn’t enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.

Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.

Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor’s bedside manner, and to seek out someone they thought would treat them well, Duke noted.

Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.

Read the full article.

 

Patient Navigators: The Missing Link to Increasing Minority Participation in Cancer Clinical Trials

From the  article on the NIMHD website:

A study conducted by the University of Alabama at Birmingham (UAB) and funded by the National Institute on Minority Health and Health Disparities that promotes the inclusion of minorities in cancer clinical trials has been selected by the American Society of Clinical Oncology to be featured in Clinical Care Advances 2016, an annual review of major advances in clinical cancer research.

The study, led by Mona Fouad, M.D., MPH, director of the UAB Minority Health and Health Disparities Research Center, focuses on the use of patient navigators as a liaison between medical staff and patients, to inform and enroll eligible African American cancer patients into clinical trials.

Dr. Fouad stated this model came as a result of the staggering disparities in clinical cancer research, currently fewer than 10 percent of patients enrolled in cancer clinical trials are minorities.

To achieve accurate results, cancer clinical trials require participation of individuals from all cultural and ethnic backgrounds, however enrollment and retention of minority groups often proves challenging.

“We started with the patient navigation model to assist under-resourced patients in our cancer center,” said Fouad. “We’ve been using patient advocates for the last two decades to promote cancer screening, but then we started thinking, ‘Well, what if they have a positive test?’ ‘How do we link them to the care needed to start treatment?’”

Patient advocates were trained to become patient navigators as a way to steer patients in the right direction to locate resources and enlist the best possible care to treat their cancer diagnosis.

“We were successful in providing this model to help patients comply and complete their cancer care, and when we accomplished that, the compliance rate was as high as 95 percent in low-income populations. So then we thought, why don’t we test this model to see not only if it helps patients to access care, but can it educate them about clinical trials as well,” said Fouad.

Fouad admitted that while many patients were reluctant at first, they came around to the idea once it was explained in detail and resources were provided to make clinical trial involvement easier for them.

“What we found by doing this is that a lot of minority patients are scared about therapeutic trials. They believe that they are experiments, and some were reluctant due to the times they’d have to be available for the trials, so the navigators were able to help with those reservations,” stated Fouad, explaining the navigators were trained to identify resources to aid trial participants.

“Navigators connected patients with social workers and did what they could to make sure all the patient had to focus on was their care and involvement in the clinical trial,” said Fouad.

While it is generally the job of medical staff to offer clinical trials to every eligible patient, the study revealed that protocol is not always followed with minority or lower socioeconomic patients.

“Sometimes, even the physician, if they know there is a patient coming from a rural area or having difficulty traveling, they tend to just not offer them clinical trials because they don’t want to increase the burden on the patient or they think the patient is not going to be a compliant participant, so, unintentionally, they just won’t offer them the trials,” said Fouad.

Read the full article.