Millions Eligible for Health Insurance Remain Uninsured

More than 15 million Americans who are currently entitled to free or subsidized health insurance are currently uninsured.

Among them are 11 million who are eligible for Medicaid but have not applied for benefits and 4.2 million who could afford insurance with the help of federal premium subsidies and either have decided not to take advantage of those subsidies or are unaware of the availability of such subsidies.

In addition, another two million people would be eligible for Medicaid if their states expanded their Medicaid program as authorized by the Affordable Care Act.

In light of such figures, it is not entirely surprising that the uninsured rate, according to the census bureau, rose last year for the first time since implementation of the Affordable Care Act.  That uninsured rate, 15 percent at the time the law was adopted in 2010, fell to 7.9 percent in 2017 but rose to 8.5 percent in 2018.  The uninsured rate has especially risen among Hispanics and the foreign born.

Another possible reason for the rise in the number of uninsured Americans:  the federal government has greatly reduced its outreach effort to inform people about the various options they have for obtaining insurance.

Learn more about who is uninsured and why the uninsured rate has risen in the Washington Post story “Millions of Americans aren’t getting health insurance, even though they’re eligible for free or affordable plans.”

 

ACA Has Reduced Insurance Disparities

The Affordable Care Act is responsible for a major reduction in the disparity of insurance status among racial and ethnic minorities.

According to a new Commonwealth Fund analysis,

All U.S. racial and ethnic groups saw comparable, proportionate declines in uninsured rates…  However, because uninsured rates started off much higher among Hispanic and black non-Hispanic adults than among white non-Hispanic adults, the coverage gap between blacks and whites declined from 11.0 percentage points in 2013 to 5.3 percentage points in 2017. Likewise, the coverage gap between Hispanics and non-Hispanic whites dropped from 25.4 points to 16.6 points.

Learn more about specific differences among racial and ethnic groups, differences based on residence in Medicaid expansion states and non-expansion states, and differences in securing public or private health insurance in the Commonwealth Fund study “Did the Affordable Care Act Reduce Racial and Ethnic Disparities in Health Insurance Coverage?”

Uninsured Rate Rose in 2017

The rate of uninsured Americans rose in 2017, the first such increase since implementation of the Affordable Care Act.

According to a new Urban Institute study,

The increasing uninsurance rate between 2016 and 2017 was driven by losses of private nongroup coverage, such as that purchased in the health insurance marketplaces, and decreases in Medicaid and Children’s Health Insurance Program (CHIP) coverage (-0.4 percentage points each).

In addition,

Overall, coverage losses were concentrated in the 19 states that did not expand Medicaid eligibility under the Affordable Care Act by July 1, 2017…Between 2016 and 2017, uninsurance held stable in Medicaid expansion states but increased by 0.5 percentage points in nonexpansion states.

The study also noted that these declines occurred at a time when the economy was considered strong, incomes were rising, and more employers were sponsoring insurance coverage.

Learn more about where and why the number of uninsured people rose in 2017 in the Urban Institute report “Health Insurance Coverage Declined for Nonelderly Americans Between 2016 and 2017, Primarily in States That Did Not Expand Medicaid.”

ACA’s Medicaid Pay Bump Helped But Benefits Now Lost, Study Says

Health status and access to care improved for Medicaid patients when the Affordable Care Act mandated a temporary rate increase for physicians serving newly insured patients covered through that law’s Medicaid expansion.

But when the mandate for increased physician payments ended and state Medicaid programs reverted to their previous, lower payments, many of those benefits were lost.

Or so reports a new study from the National Bureau of Economic Research.

According to the study, even a $10 rate increase improved access to care enough to reduce by 13 percent Medicaid recipients’ complaints about not being about to find a doctor.  Utilization also increased.  The temporary Medicaid pay increase has even been credited with improving school attendance and reducing chronic absenteeism.

Despite the benefits of the temporary increase in Medicaid payments to physicians, most states returned to lower payments when the mandated ended, most of the gains resulting from the better pay for treating Medicaid patients disappeared, and the disparities between privately insured individuals and Medicaid patients returned to their pre-Affordable Care Act levels.

Researchers estimate that increasing Medicaid payments to physicians by an average of $26 a visit would eliminate disparities in access to care.

These findings are especially relevant to private safety-net hospitals because the communities they serve have so many more Medicaid patients than the typical American community.

Learn more from the National Bureau of Economic Resarch study “The Impacts of Physician Payments on Patient Access, Use, and Health” and from the Healthcare Dive report “Even $10 increase in Medicaid payments helps erase disparities in care access, study says.”

Medicaid DSH Delay Advances in Energy and Commerce Committee

Medicaid disproportionate share cuts would be delayed for two years under a proposal advanced last week by the Health Subcommittee of the House Energy and Commerce Committee.

The Medicaid DSH cuts, mandated by the Affordable Care Act, have already been delayed three times by Congress and could be on their way to a fourth delay if the proposal advanced by the Health Subcommittee is endorsed by the Energy and Commerce Committee and works its way to the full House of Representatives, where such a proposal is thought to enjoy wide support.

The National Alliance of Safety-Net Hospitals has long endorsed the delay and even the repeal of cuts in Medicaid DSH payments, doing so most recently in a letter earlier this year to Senate Finance Committee chairman Charles Grassley in which it argues that those cuts would be especially harmful to private safety-net hospitals.

Learn more about the possibility of another delay of Medicaid DSH cuts in the HealthLeaders article “House Panel Advances Surprise Bill Package.”

 

ACA Tied to Reduced Disparities in Cancer Care

Improved access to health insurance has led to reduced racial disparities in the diagnosis and treatment of cancer.

As reported by the Washington Post,

According to researchers involved in the racial-disparity study, before the ACA went into effect, African Americans with advanced cancer were 4.8 percentage points less likely to start treatment for their disease within 30 days of being given a diagnosis.  But today, black adults in states that expanded Medicaid under the law have almost entirely caught up with white patients in getting timely treatment, researchers said.

Another study found that since the reform law’s implementation in Medicaid expansion states, women are being diagnosed and treated earlier for ovarian cancer than they were in the past.

Many of these patients receiving more timely care are served by private safety-net hospitals, which care for more Medicaid patients than most community hospitals.

Researchers also note that disparities, so often viewed from a racial and socio-demographic perspective, are now being seen on a geographic basis depending on whether individual states expanded their Medicaid program.  As one observer explained,

We are moving from black-white disparities to Massachusetts versus Mississippi disparities.

Learn more from the Washington Post article “ACA linked to reduced racial disparities, earlier diagnosis and treatment in cancer care.”

 

Medicaid Expansion Helps Pregnant Women and Their Babies

An intuitive assumption now has evidence to support it:  Medicaid expansion has improved the health of pregnant women and their babies.

According to a new study from the Georgetown University Health Policy Institute’s Center for Children and Families,

…states that expand Medicaid improve the health of women of childbearing age:  increasing access to preventive care, reducing adverse health outcomes before, during and after pregnancies, and reducing maternal mortality rates.

Better health for women of childbearing age also means better health for their infants.  States that have expanded Medicaid under the Affordable Care Act saw a 50 percent greater reduction in infant mortality than non-expansion states.

Learn more, including specific health benefits enjoyed by pregnant women and their babies, in the Georgetown study “Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies.”

Medicaid DSH Delay Wins Bipartisan Support

More than 300 members of the U.S. House have joined a letter to House leadership urging a delay in Affordable Care Act-mandated cuts in Medicaid disproportionate share payments (Medicaid DSH).

The bipartisan letter notes that hospitals that receive Medicaid DSH funds cannot absorb the loss of revenue such a cut would bring.  That cut, scheduled to begin in FY 2020, would amount to a $4 billion reduction in nation-wide Medicaid DSH spending in FY 2020 and an $8 billion reduction in each of FY 2021, FY 2022, FY 2023, FY 2024, and FY 2025.

NASH was actively involved in urging House members to join the letter.  If implemented, the Medicaid DSH cuts would be especially harmful to NASH members and all private safety-net hospitals – and to the low-income residents of the communities they serve.

See the bipartisan letter seeking a delay of Medicaid DSH cuts here.

More Medicaid Matching Funds for Only Partial Medicaid Expansion?

The federal government is considering providing an unusual amount of federal Medicaid matching funding for only partial state Medicaid expansion.

At least that’s what Centers for Medicare & Medicaid Services administrator Seema Verma told a health care conference in Georgia last week.

The state of Georgia has proposes partially expanding its Medicaid population.  Under the Affordable Care Act, states that fully expand their Medicaid programs under the terms established by the 2010 health care law receive nine dollars in federal matching funds for every one dollar they spend on their Medicaid expansion population.  States that only partially expand their Medicaid programs, on the other hand, currently are eligible to receive only their usual federal matching rate:  generally one federal dollar for every state dollar, with states with higher poverty rates receiving as much as slightly more than three dollars for every state dollar they spend.

Last week, however, CMS’s Verma said that when Georgia submits its Medicaid waiver application to CMS seeking only partial expansion of its Medicaid program, the federal agency will consider providing Affordable Care Act-level Medicaid matching funds rather than the traditional federal Medicaid matching rate.

Such a policy shift could be very beneficial for private safety-net hospitals in states that have not expanded their Medicaid programs, extending coverage to some of the currently uninsured, low-income residents of the communities in which those hospitals are located.

Learn more about the Georgia plan for partial Medicaid expansion and the possibility of CMS treating it like an Affordable Care Act Medicaid expansion in the Atlanta Journal-Constitution article “Trump official open to increased funding for Georgia Medicaid waiver.”

Uninsured ED and Inpatient Visits Down Since ACA

Uninsured hospital admissions and emergency department visits are down since passage of the Affordable Care Act.

And Medicaid-covered admissions and ER visits are up, according to a new analysis.

The report, published on the JAMA Network Open, found that ER visits by uninsured patients fell from 16 percent to eight percent between 2006 and 2016, with most of this decline after 2014, while uninsured discharges fell from six percent to four percent.

The rate of uninsured ER visits declined, moreover, at a time when overall ER visits continued to rise.

While the Affordable Care Act is likely the cause of most of these changes, other contributing factors include the emergence of urgent care facilities, telemedicine, and free-standing ERs as well as new payment models and rules.

The study’s findings are especially good news for private safety-net hospitals because they care for so many more low-income patients than other hospitals and have benefited from the Affordable Care Act’s expansion of access to insurance, whether through Medicaid expansion or the private health insurance market.

Learn more in the JAMA Network Open article “US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act.”