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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.”

Delay Medicaid DSH Cuts, Pelosi Says

Medicaid DSH cuts should be delayed, House Speaker Nancy Pelosi (D-CA) told a gathering of hospital officials.

According to Speaker Pelosi,

DSH cuts threaten to erode the health of community hospitals, safety-net hospitals and rural hospitals, [affecting] the health of not only the families that rely on Medicaid, but any person who relies on these hospitals for care.

NASH has long urged Congress to delay or even eliminate Affordable Care Act-mandated cuts of Medicaid disproportionate share payments, doing so twice in the past week: first in a letter to Senate Finance Committee chairman Charles Grassley (R-IA) and then in a message to all House members. NASH believes this cut would be especially harmful for the nation’s private safety-net hospitals.

Learn more about Speaker Pelosi’s remarks in the Becker’s Hospital Review article “House speaker urges Congress to ease Medicaid payment cuts to hospitals serving low-income patients.”

NASH Asks House to Support Delay of Medicaid DSH Cut

Working to prevent the scheduled October 2019 reduction of Medicaid DSH allocations to the states, NASH has reached out to the House of Representatives for help.

In a message delivered to all House members, NASH asked those members to sign onto a bipartisan letter being circulated by two of their colleagues, Representatives Eliot Engel (D-CA) and Pete Olson (R-TX), that asks House Speaker Nancy Pelosi (D-CA) and minority leader Kevin McCarthy (R-CA) to advance legislation to delay an Affordable Care Act-mandated reduction of Medicaid disproportionate share allocations to the states.  Congress has already delayed this cut three times.

In its letter, NASH explains that

If implemented, this cut would be harmful for private safety-net hospitals and the communities they serve throughout the country.

See the Engel-Olson letter here and see NASH’s message to House members here.

ACA Repeal Would Drive Up Uninsured, Uncompensated Care

At the same time that the Trump administration announced that it has asked a federal court to repeal the entire Affordable Care Act, the Urban Institute has published a report detailing the potential impact of the health care reform law’s repeal.

According to the Urban Institute report, repealing the entire Affordable Care Act would add almost 20 million Americans to the ranks of the uninsured.  Medicaid and CHIP enrollment would fall by 15.4 million people and millions of others would lose the tax credits they used to purchase insurance.  Some would purchase insurance with limited benefits and individual plan premiums would rise while others would go uninsured.

In addition, repeal of the Affordable Care Act would lead to an 82 percent increase in hospital uncompensated care, to more than $50 billion.  About half of the states would see the amount of uncompensated care provided by their hospitals double, the Urban Institute estimates.

Repeal of the Affordable Care Act would pose an especially great financial challenge for private safety-net hospitals because they care for so many Medicaid- and CHIP-covered and low-income patients who might lose their coverage if the reform law is repealed.

Learn more from the Healthcare Dive article “Killing ACA would lead to huge spikes in uncompensated care” and from the Urban Institute report State-by-State Estimates of the Coverage and Funding Consequences of Full Repeal of the ACA.

 

MACPAC: Slow Medicaid DSH Cuts

Slow the pace of scheduled cuts in Medicaid disproportionate share hospital payments (Medicaid DSH), the non-partisan agency that advises Congress and the administration will tell Congress in its next report of policy recommendations.

The Medicaid and CHIP Payment and Access Commission voted 16-1 recently to recommend to Congress that Medicaid DSH cuts, mandated by the Affordable Care Act but delayed three times by Congress, be reduced in size and spread out over a longer period of time.

Currently, Medicaid DSH allotments to the states are scheduled to be reduced $4 billion in FY 2020 and then $8 billion a year in FY 2021 through FY 2025.  MACPAC recommends that the cuts be reduced to $2 billion in FY 2020, $4 billion in FY 2021, $6 billion in FY 2022, and $8 billion a year from FY 2023 through FY 2029.

MACPAC commissioners also voted to urge Congress to restructure the manner in which Medicaid DSH allotments to the states are calculated based on the number of low-income individuals who reside in the states.

Most private safety-net hospitals receive Medicaid DSH payments and consider them a vital resource in helping to underwrite the uncompensated care they provide to uninsured patients.  NASH supports delaying the implementation of Medicaid DSH cuts and reducing the size of the cuts once implementation begins, doing so most recently in a letter to Senator Marco Rubio in response to Mr. Rubio’s introduction of Medicaid DSH legislation.

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program.

Learn more about MACPAC’s actions on Medicaid DSH in the Fierce Healthcare article “MACPAC calls for Congress to delay cuts to safety-net hospitals.”

CMS Introduces New Waivers

The Centers for Medicare & Medicaid Services has introduced four new “state relief and empowerment waivers” that are widely viewed as new vehicles for states to circumvent Affordable Care Act requirements to implement their own new approaches to health care.

  • Through “account-based subsidies” waivers, states may direct public subsidies into defined-contribution, consumer-directed accounts that individuals use to pay for health insurance premiums or other health care expenses.
  • “State-specific premium assistance” waivers enable states to create their own subsidy programs.
  • “Adjusted plan options” authorizes states to provide financial assistance for different types of health insurance plans, including short-term and other health insurance policies that do not meet Affordable Care Act benefits and coverage requirements.
  • “Risk stabilization strategies” waivers give states greater flexibility to implement reinsurance programs or high-risk pools.

These waiver options have been introduced not through regulations but through guidance published in the Federal Register.  States must apply for these waivers, which must meet section 1332 federal standards for  comprehensiveness, affordability, coverage, and federal deficit neutrality.

Learn more about state relief and empowerment waivers in this CMS fact sheet and this guidance that was published in the Federal Register.

Pay Raise Didn’t Lead More Docs to Participate in Medicaid

The temporary rate increase that the Affordable Care Act provided as means of encouraging more doctors to serve Medicaid patients did not work, according to two new studies published in the journal Health Affairs.

According to the studies, the increase in the number of physicians who decided to begin serving Medicaid patients as a result of the fee increase was negligible.

Among the reasons the studies’ authors offer for the lack of growth in the participation of doctors are the limited nature of the pay raise and the documentation required to receive it.

Despite this, the authors note, access to care did improve as a result of the Affordable Care Act’s Medicaid expansion.

Learn more about the studies, their results, and their significance by going here to see the Health Affairs report “No Association Found Between The Medicaid Primary Care Fee Bump And Physician-Reported Participation In Medicaid and here for the study “Physicians’ Participation In Medicaid Increased Only Slightly Following Expansion.”

Verdict: Medicaid Expansion Improved Care and Access

A new review of studies published since the Affordable Care Act’s Medicaid expansion has concluded that expansion improved care, access to care, and coverage in states that expanded their Medicaid programs.

Among the improvements cited by studies are:

  • greater use of primary care
  • more preventive health visits
  • more behavioral health care
  • shorter hospital stays
  • fewer avoidable hospital admissions
  • reduced access problems
  • reduced reliance on hospital ERs as a primary source of care
  • improved monitoring and compliance rates for patients with diabetes and hypertension
  • higher rates of screening for prostate cancer and Pap smears

In addition, hospitals provided less uncompensated care and had better margins.

Learn more in the Health Affairs study “The Effects Of Medicaid Expansion Under The ACA:  A Systematic Review,” which can be found here, or go here for a Healthcare Dive summary of the study.

ACA Has Increased Primary Care Utilization

A new study found that the increase in the number of insured Americans as a result of the Affordable Care Act has resulted in increased utilization of primary health care services.

According to a study by the National Bureau of Economic Research, primary care utilization rose 3.8 percent, mammograms 1.5 percent, HIV tests 2.1 percent, and flu shots 1.9 percent over a three-year period.  The study suggests that preventive care increased between 17 and 50 percent.

The study attributes all of the gains to improved access to private insurance and none to Medicaid expansion.

These results are based on self-reported information gathered from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System.

Learn more about these and other study findings in the National Bureau of Economic Resarch report  “Effects of the Affordable Care Act on Health Behaviors after Three Years” or see this summary on the Healthcare Dive web site.

Study Looks at Medicaid and Managed Care

A new Commonwealth Fund study examines how managed care plans have tackled serving new members in Affordable Care Act-authorized Medicaid expansion states.

According to the report, these managed care organizations have

…focused on identifying and helping high-risk populations and addressing the social determinants of health. MCOs are testing value-based payment strategies that link payment with performance and are increasingly focused on engaging patients in their care. Leaders report common challenges: setting appropriate payment rates; managing members whose needs differ from traditional Medicaid beneficiaries; ensuring access to specialty care; and effectively implementing payment reform and practice transformation.

Learn more about how managed care plans have served the Medicaid expansion population in the Commonwealth Fund report “Medicaid Payment and Delivery Reform:  Insights From Managed Care Plan Leaders in Medicaid Expansion States,” which can be found here.