Improving Insurance Enrollment for Legal Immigrants

While the Affordable Care Act has led to impressive increases in the number of Americans with health insurance, the current enrollment poses a number of challenges for legal immigrants: those in the U.S. legally who lack insurance and are qualified to obtain coverage through the federally facilitated marketplace and state exchanges.

georgetownResearchers at the Georgetown Center for Children and Families have identified a number of obstacles to enrollment for legal immigrants, including complicated applications, and have recommended ways of addressing this and other obstacles standing in the path of legal immigrants obtaining health insurance.

This is an important issue for the many private safety-net hospitals that serve communities with large immigrant populations.

To learn more about the special challenges legal immigrants face and proposals for overcoming those challenges, see this Georgetown Center for Children and Families report Getting Enrollment Right for Immigrant Families: Steps the Federally Facilitated Health Insurance Marketplace Can Take to Improve the Application Process for Eligible Lawfully Present Immigrants.

Hospitals, Non-Profit Status, and Community Benefit

For years debate has raged over what non-profit hospitals must do to retain that non-profit status. That debate has gone from a general concept of what constitutes “community benefit” to local government challenges to the non-profit status of hospitals based on the general notion that they were not providing enough community benefits to merit the special tax status.

The debate was raised to a new level in 2010 when the Affordable Care Act established, for the first time, national standards detailing what hospitals must do to retain their tax-exempt status.

health affairsIn a new issue brief, the journal Health Affairs takes a closer look at community benefit and the Affordable Care Act: the conditions that led to a desire to address community benefit in the 2010 reform law, the issues that define the debate, what the reform law requires, and how the law’s requirements may be policed and enforced.

Many private safety-net hospitals are non-profit.

Find the Health Affairs issue brief “Nonprofit Hospitals’ Community Benefit Requirements” here.

Cutting ER Visits: Harder Than Expected

The first two years of major expansion of access to health insurance under the Affordable Care Act did not produce the significant reduction in hospital ER visits that many expected.

Or so reports a new study from the Centers for Disease Control and Prevention.

According to the CDC, even though eight million people gained health insurance under the health reform law in 2013 and 2014, ER visit rates changed little.

iStock_000000522737XSmallStill, the CDC survey found some progress: visits among Medicaid patients and the uninsured fell slightly, although Medicaid patents still frequent hospital ERs more than the privately insured.

Among those who did visit the ER, many said their primary care practice was not open at the time or that the ER was the only provider to which they felt they had access to care. In addition, many who made ER return visits reported doing so because of local government reductions of behavior health services options.

Because they are located in low-income communities, private safety-net hospitals typically have far more ER visits than the average hospital.

Learn more about changing rates of ER visits during the first years under the Affordable Care Act in this Fierce Healthcare article or go here to see the CDC report Reasons for Emergency Room Use Among U.S. Adults Aged 18–64: National Health Interview Survey, 2013 and 2014.

New Medicaid Enrollees Cost Less to Serve

Contrary to fears that the long-time uninsured who became eligible for Medicaid under Affordable Care Act eligibility expansion would turn to providers with a long litany of expensive-to-treat medical problems, preliminary data suggests that such individuals are actually less costly to treat than the average Medicaid recipient.

Preliminary data released by the Centers for Medicare & Medicaid Services based on claims data from the first quarter of 2014 – the first time period after Medicaid expansion began in some states – found that the average new adult Medicaid enrollee cost $4513 to serve, as opposed to the $7150 it cost to serve Medicaid beneficiaries across all groups.

kaiserThe Kaiser Family Foundation has done a great deal of analysis of early data under Medicaid expansion, looking at costs per beneficiary, geographic data, Medicaid expansion states, enrollment changes, and more. Find its extensive analyses here in the report “Medicaid Expansion Spending and Enrollment in Context: An Early Look at CMS Claims Data for 2014.”

Dual Eligible Programs Show Mixed Results

The Affordable Care Act-inspired effort to find more effective ways to serve the so-called dual eligible population – mostly the disabled and low-income elderly covered by both Medicare and Medicaid – is not providing the kind of results policy-makers expected when they initiated new efforts to serve this high-cost population.

But not all of the news is bad.

iStock_000008112453XSmallOn one hand, enrollment figures for those eligible to participate have not met expectations, with some of those eligible afraid they might lose their providers and some of those providers persuading their patients not to participate. In addition, some health plans that participated in the earliest efforts have withdrawn in the face of declining enrollment.

On the other hand, employing care managers to serve members has shown signs of reducing hospitalizations and Medicare costs and individuals who do participate have expressed satisfaction with the service they are receiving.

Programs that serve dually eligible individuals are of special interest to private safety-net hospitals because the communities they serve typically have especially large numbers of such residents.

For a closer look at the effort’s expectations, where it has succeeded, and where it has encountered challenges, see this Wall Street Journal article.

Feds Seek to Regulate Narrow Networks

Amid concerns that low-cost health plans are reducing their provider networks to contain costs at the expense of access to care for their members, the Centers for Medicare & Medicaid Services (CMS) is proposing new guidelines to limit how much those provider networks can be narrowed.

According to a CMS fact sheet,

To protect consumer access to health care providers and delivery organizations, the proposal asks states to establish a provider network adequacy standard for health plans in the federal Marketplace, subject to minimum criteria that CMS will establish at a later date, with a default time and distance standard otherwise. CMS is evaluating additional efforts to support transparency and informed consumer decision-making as it relates to provider network adequacy, and is requesting comment on whether designated network strength – for instance, indicating whether a plan has a broad number of doctors or health facilities in their network to choose from or not – could improve the consumer experience in future years.

federal registerThe proposed regulation also would require insurers to

…count certain out-of-pocket expenses on unexpected out-of-network services towards a policy holder’s annual out-of-pocket maximum, if the service was performed at an in-network facility and advance notice was not provided.

For a closer look at these proposals and others that are part of CMS’s proposed improvements for the 2017 federal insurance market, see this CMS news release; this CMS fact sheet; and the proposed regulation itself. Interested parties have until December 21 to submit comments on CMS’s proposed regulation.

One State’s Battle With DSH Cuts

Hospitals across the country are concerned about the degree to which the Affordable Care Act is reducing the Medicare disproportionate share hospital (Medicare DSH) payments that help underwrite the cost of the care they provide to uninsured patients.

Those in states that have expanded their Medicaid programs are now receiving payments for at least some of those formerly uninsured patients because those individuals are now enrolled in Medicaid. In states that did not expand their Medicaid programs, however, hospitals face challenges coming from two directions: reduced Medicare DSH payments without the benefit of some of those uninsured patients enrolling in Medicaid.

Health Care Reform/FlagThe state of Louisiana has not expanded its Medicaid program, and now, policy-makers there are faced with the question of how to finance their unexpanded Medicaid program in the face of reduced – and falling – Medicare DSH revenue.

The National Association of Urban Hospitals has long opposed the Affordable Care Act’s Medicare DSH cuts and has called on Congress to delay or repeal them.

Read more about the challenges that state faces and the role of Medicare DSH cuts in those challenges in this article from the Times-Picayune.

Increases in Medicaid Enrollment Should Slow

Growth in Medicaid enrollment, significant this year and last, should slacken in 2016, according a new Kaiser Family Foundation report.

That growth – 8.3 percent in 2014 and 13.8 percent in 2015 – should fall to approximately four percent next year. The upswing is the result of Medicaid expansion authorized by the Affordable Care Act and most of the growth was in states that expanded their Medicaid programs, although in 2015 every state experienced an increase in Medicaid enrollment.

kaiserGrowth in Medicaid spending, too, is expected to decline, from 14.3 percent in 2014 and 13.9 percent in 2015 to a projected 6.9 percent in 2016.

To learn more about how, where, and why Medicaid enrollment and spending continue to grow, see this CQ HealthBeat report presented by the Commonwealth Fund.

Low-Income Workers Rejecting Health Insurance

Low-wage workers offered health insurance by their employers are largely rejecting that option, according to a report in the New York Times.iStock_000014445371XSmall

According to the Times, most of the progress in reducing the number of unemployed Americans has been made through Medicaid expansion and subsidies offered through the federal and state health exchanges. As small businesses begin to be required to offer their workers unsubsidized insurance, however, they are finding that most of their lower-wage employees are rejecting the offer. As a result, 7.5 million people last year paid the Affordable Care Act fine for failing to obtain health insurance.

A review of the profile of those who choose not to purchase employer-sponsored health insurance found that workers who earn between $15,000 and $20,000 a year purchase insurance only 37 percent of the time and that only when income rises to $45,000 does the health insurance purchase rate increase significantly.

For more information about who is and is not buying employer-sponsored health insurance and why, see this New York Times article.

Will Growing Medicaid Costs Swamp State Budgets?

Many states that expanded their Medicaid programs under the Affordable Care Act have experienced far greater increases in enrollment than projected and are now worried about their future ability to pay for the increased costs associated with that greater enrollment.

Medicaid enrollment growth in California was three times projected growth and in Kentucky it was twice the anticipated amount. Overall, more than a dozen states have experienced increases in enrollment that far exceeded their projections and many are now revising their spending projections to reflect those increases.

iStock_000015725011XSmallThe federal government is paying the full cost of Medicaid expansion through 2016 but will begin to pay less in 2017 until, by 2020, the state share of Medicaid expansion will be 10 percent of those expansion costs.

While some state officials worry about where they will find the money to pay the unexpected costs, others maintain that they will save money in the long run because they will be able to eliminate some state programs that serve the uninsured, including supplemental payments to hospitals, and the job creation associated with serving more patients will stimulate state economies and generate more tax revenue.

Learn more about the challenges unexpectedly great Medicaid enrollment is posing to some states and how those states are responding to those challenges in this Associated Press report.