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.

 

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.

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.

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.