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.

Health Care Outcomes in States Influenced by Coverage, Disparities

From the article by Kimberly Leonard in US News:

Enjoying longer, healthier lives than the average American, and with strong medical coverage and access to care, Hawaiians rank No. 1 in the country for health care, according to the U.S. News analysis of federal data supporting the Best States rankings. But Hawaii has more than a mild climate and residents who share a proclivity for outdoor activities to contribute to its success. The state had a significant head start: a four-decade jump on health care reform.

“It was a really wonderful exciting time and one that’s kind of forgotten by the rest of America,” says Dr. Jack Lewin, who oversaw the state’s implementation of the Prepaid Health Care Act as health agency director.

As a result of the law’s passage, Hawaii became the first state in the country to implement a nearly universal health care system for its residents, enforcing a mandate for all employers whose employees work a minimum of 20 hours a week. The model, originally proposed by President Richard Nixon, would later become the inspiration for Hillary Clinton’s unsuccessful attempts at national health care reforms in her role as first lady in the 1990s.

Though never implemented nationally, the law in Hawaii, as well as measures in other states that have been particularly proactive, provides strong evidence that increasing access to health care coverage has contributed to wellness, according to the data compiled for Best States.

In Hawaii, residents have steady access to preventive care such as screenings and doctor visits, and are among the least likely to report that they skipped needed medical care because of cost. Mortality rates are the lowest in the country, giving Hawaiians the longest life expectancy in the U.S. Their obesity and infant mortality rates also are among the lowest in the country.

Experts say the Hawaiian experience helps give credence to those who say health care coverage is fundamental to reforming the American health care system, noting that people who are uninsured often skip needed testing, care or medicines because of concerns about cost.

“There is a large body of research showing that people who have health insurance are likely to access care and to get appropriate care like cancer screenings, and that leads to ultimately better health outcomes,” says Rachel Garfield, associate director for the program on Medicaid and the Uninsured at the Kaiser Family Foundation, which studies health care.

The U.S. News rankings examine not only how well residents are, but whether they can access medical care and how good that care is. Each of these three components is given equal weight for a final score. The results appear to suggest some parallels across states that tend to be more engaged.

“Higher performing states have huge efforts over time to reform or improve their health care system, and government plays a very important leadership in that,” says Douglas McCarthy, senior research director of the Commonwealth Fund, a foundation that releases studies on health care issues. “The stakeholders are very engaged and created a culture of collaboration. It’s really about bringing everyone to the table.”

Read the full article.

Treatment Gaps Persist Between Low- And High-Income Workers, Even With Insurance

From the article by Michelle Andrews on Kaiser Health News:

Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn’t result in hospitalization, a new study found.

At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.

There’s no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study’s lead author, which was published in the February issue of Health Affairs.

Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.

Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.

“Individuals are penalized if they leave work to seek care,” Sherman said. “So they go after hours and their access to care is limited to urgent care centers or emergency departments.”

The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.

Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.

Read the full article.


Understanding the Intersection of Medicaid and Work

From the issue brief by Rachel Garfield, Robin Rudowitz, and Anthony Damico from the Kaiser Family Foundation:

Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers more than 70 million Americans, or 1 in 5, including many with complex and costly needs for care. Historically, non-elderly adults without disabilities accounted for a small share (27%) of Medicaid enrollees; however, the Affordable Care Act (ACA) has expanded coverage to non-elderly adults with income up to 138% FPL, or $16,394 for an individual in 2016. As of January 2017, 32 states have implemented the ACA Medicaid expansion. By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. With the expansion to more “able-bodied” adults, questions have arisen about tying work to eligibility.

President Trump may consider waiver proposals with a work requirement, and the Administration and leaders in Congress are considering proposals to repeal the ACA and to transform Medicaid from an entitlement program with guaranteed federal matching dollars for states to a block grant with no entitlement and capped funding. Such proposals would grant states additional flexibility to design and administer their programs and potentially include an option to allow states to impose a work requirement for Medicaid beneficiaries, which is not allowed under current law.  This issue brief examines the work status of non-elderly adults without SSI enrolled in with Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid.

The brief provides an overview of work status of adult Medicaid enrollees and examines some of the policy proposals around tying Medicaid coverage to work.

  • Among Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion) nearly 8 in 10 live in working families, and a majority are working themselves. However, nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low ESI offer rates.
  • Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work.
  • Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states have sought to impose a work requirement for the Medicaid expansion population through waivers; the prior administration did not approve these requests.  The issue of work requirements may be re-examined by the new administration and may be debated in Congress as part of broader efforts to restructure Medicaid financing and core federal requirements.


Read the full brief.

Download the issue brief.

What Made Obamacare Succeed In Some States? Hint: It’s Not Politics

From the article by Stephanie O’Neill on Kaiser Health News:

Ask anyone about their health care and you are likely to hear about ailments, doctors, maybe costs and insurance hassles. Most people don’t go straight from “my health” to a political debate, and yet that is what our country has been embroiled in for almost a decade.

A study out Thursday tries to set aside the politics to examine how the insurance markets function and what makes or breaks them in five specific states.

Researchers from The Brookings Institution were exploring a basic idea: If the goal is to replace or repair the Affordable Care Act, then it would be good to know what worked and what failed.

“The political process at the moment is not generating a conversation about how do we create a better replacement for the Affordable Care Act,” said Alice Rivlin, senior fellow at The Brookings Institution, who spearheaded the project. “It’s a really hard problem and people with different points of view about it have got to sit down together and say, ‘How do we make it work?’”

he researchers focused on California, Florida, Michigan, North Carolina and Texas, interviewing state regulators, health providers, insurers, consumer organizations, brokers and others to understand why insurance companies chose to enter or leave markets, how state regulations affected decision making and how insurers built provider networks.

“Both parties miss what makes insurance exchanges successful,” said Micah Weinberg, president of Bay Area Council Economic Institute who led the California research team. “And it doesn’t have anything to do with red and blue states and it doesn’t have anything to do with total government control or free markets.”

Despite the political diversity of the five states, some common lessons emerged. Among them:

  • Health Insurance Markets Are Local
  • Consolidation Kills Competition
  • More Sick People Signed Up Than Expected
  • Some Consumers May Be “Gaming” The System
  • Narrow Networks Appear To Be The New Normal
  • The Sky May Be Falling, But Many Carriers Are Nevertheless Doing Well
  • Medicaid Managed Care Plans Come Out Winners

Read the full article.


An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana

From the Issue Brief by MaryBeth Musumeci, Robin Rudowitz, Petry Ubri, and Elizabeth Hinton from the Kaiser Family Foundation:

Michigan and Indiana are among the seven states using a Section 1115 demonstration waiver to implement Medicaid expansions in ways that differ from the terms of the Affordable Care Act (ACA).  While each waiver is unique, Michigan and Indiana’s waivers include some similar provisions.  Some of these features are not found in other waivers approved to date, although additional states have expressed interest in pursuing similar models.

This issue brief explains some of the key components in Michigan and Indiana’s waivers and presents insights based on their early implementation experiences.  The findings are based on 22 in-person and telephone interviews conducted in July and August, 2016 with state officials, providers, health plans, beneficiary advocates, and enrollment assistors in Michigan and Indiana, and incorporate data and reports from the state Medicaid agencies and other publicly available sources. We also conducted four focus groups (two in each state) with beneficiaries enrolled in waiver coverage to learn about their firsthand experiences.

Insights gained through the research include:

  • Medicaid expansion design, whether through traditional state plan authority or waivers, is highly dependent on the features of a state’s underlying Medicaid program.
  • Implementation of complex programs involves collaboration with a variety of stakeholders, sophisticated IT systems, and administrative costs.
  • Premium costs and complex enrollment policies can deter eligible people from enrolling in coverage.
  • Health accounts can be confusing for beneficiaries.
  • Beneficiary and provider education and tangible incentives appear central to implementing healthy behavior incentive programs.

Read  or download the full Issue Brief.

Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons

From the policy brief  by Anna Spencer, Bianca Freda, Tricia McGinnis, and Laura Gottlieb of the Center for Health Care Strategies, Inc.:

Social determinants of health (SDOH) are conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect health outcomes and risks, functioning, and quality-of-life. These social, economic and environmental conditions, in addition to health behaviors, relate to an estimated 80 percent of health outcomes in the United States. Moreover, behavioral patterns/health-risk behaviors (40%), social circumstances (15%), and environmental exposures (5%) play a significant role in premature death in this country (Exhibit 1). These determinants of health disproportionately affect those in low-income brackets.

Given Medicaid’s role in serving people with complex clinical, behavioral health, and social needs, state Medicaid agencies are uniquely positioned to identify and help address these diverse social challenges. In recent years, many of these agencies have developed strategies to support providers in addressing patients’ SDOH that complement more traditional medical care delivery programs. Some state Medicaid agencies have started to integrate coverage for interventions focused on SDOH into new value-based payment models. Many Medicaid managed care organizations (MCOs) are also developing interventions that address SDOH by linking clinical and non-clinical service delivery to improve health outcomes and cost efficiencies. At the federal level, the Center for Medicare and Medicaid Innovation (CMMI) is planning to test whether Accountable Health Communities (AHC) are a cost effective approach to identifying and addressing select unmet social needs of Medicare and Medicaid beneficiaries across the country.

Collecting information on social risks — including access to food and housing and employment status — is a key component of developing and implementing interventions to address these risks. Select providers and health care organizations are pioneering strategies to collect and use patient-level SDOH information to better direct interventions. These efforts, however, are not universal. Medicaid can play a key role in driving consistent measurement, collection, and use of SDOH data among health plans and providers. Little is known, however, about Medicaid and public health efforts to assess SDOH among Medicaid beneficiaries, including the degree to which standardized SDOH measures are used.

Building on previous CHCS work on health-related supportive services in Medicaid, CHCS sought to learn more about SDOH data collection by Medicaid and other state agencies, including whether there was any standardization across programs and how the data was being used. CHCS conducted interviews with more than 30 key informants representing eight states, as well as the Center for Medicare and Medicaid Innovation, the Association for Community Affiliated Plans, and a Medicaid MCO to better understand how states collect and apply beneficiary SDOH data. These interviewees represented diverse perspectives, including Medicaid and public health department officials, metrics managers, and experts in data analysis, health information policy, and informatics. Drawing from the interviews, this brief explores: (1) how states define and collect patient-level SDOH information; (2) processes for measures selection; (3) the multi-pronged ways Medicaid and other state agencies are using SDOH data at the patient and population level; (4) challenges to capturing and using SDOH data; and (5) key considerations for Medicaid in advancing SDOH measurement approaches. The information gleaned from the interviews offer valuable early lessons to help policymakers and researchers drive greater and more consistent collection of patient level SDOH information.

Download the full document.

Health Coverage is My Road to Independence

From the article by Mary Leapart on

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.