Kansas State University


Issues in Health Reform

Category: enrollments

Persisting disparities in who is insured

While overall the US is experience decreasing rates of people uninsured, these gains are not shared among the races equally.  Racial disparities that are related to more people of color working in part time and/or lower paying jobs, and in general, increase the rates of poverty among blacks and other nonwhites, are also having an impact on who gets health insurance.

Most of those part time and lower paying jobs do not come with health insurance.  Fortunately, there are now options in the state and federally run Marketplaces where many can purchase health insurance without worrying about pre-existing conditions excluding them.  Also, in many cases, people are eligible to receive substantial financial assistance in paying for premiums (Advance Premium Tax Credits) and the cost-sharing portions of insurance (Cost Sharing Subsidies).

However, in order to qualify for that financial assistance the family income must be above the federal poverty line ($11,880 for an individual; $24,300 for a family of 4).  In the 18 states where Medicaid has expanded to include individuals under 138% of that level, there are options for those who are ineligible to receive financial assistance.  Those individuals are insured through their states’ Medicaid systems.

In the 32 states that have not expanded however, there are no affordable options for insurance.   This is where we observe being poor and without a job that offers health insurance to impact racial minorities the hardest.   (The one exception is Wisconsin that has its own Medicaid coverage outside of the federal Expansion.)  And, as all uninsured people, those without coverage do often use health care, but they access care at inappropriate times (less preventive, more acute and severe care needs), and in inappropriate places (emergency rooms for routine care).  Finding a way to insure this population or provide them with more consistent health care would improve their health outcomes and community outcomes that thrive with a healthy workforce.

This issue is covered in detail in a news article and in a Kansas Health Institute issue brief.

How is the ACA faring according to enrollment criteria or what do the enrollment numbers mean?

If one uses as a standard the Forbes article analyzing recently released Census Bureau data ACA is performing at 71% of expected enrollment and is therefore a failure. True that the Census data used in that article in all new reports are likely more accurate than earlier reports based on smaller samples that had shown more hopeful progress. Still, I find it odd, to say the least, to call a drop in the rates of uninsured of about 8% overall to be a failure. The ASPE DHHS national data report now shows 17.6 million uninsured gaining health insurance coverage through the Health Insurance Marketplaces, Medicaid, and also including individual private market coverage.

The ASPE report also notes that the decreases in the uninsured has differentially affected racial and ethnic groups. The largest decline was among African Americans where the uninsurance rate was halved from 22.4% to 12.1%, 2.6 million people gaining insurance.  Hispanics had farther to go. They started at 41.8% uninsured and are now at 30.3%. That is still a high rate of uninsured that is complicated by matters of documentation but a significant drop nonetheless and affecting 4 million real lives. Whites had, and continue to have, the lowest rates of uninsurance among those three groups. They started at 14.3% and have declined to 8.3%, impacting 7.4 million lives.

Those are significant numbers of Americans now being insured and having much more balanced access to health insurance. No one can be denied a policy because they are sick. No one’s policy can be cancelled because they are sick. There are no longer annual nor lifetime maximums on the amount paid out for covered services. In a nutshell, not only are all of the new folks insured and protected, but most who are insured through employer plans also now share those same protections (there are exceptions for self-funded plans and for the small percentage still grandfathered in under old regulations). Further, this ability to access insurance through a place other than a place of employment has opened up opportunities for those who want to leave their current places of employment. In the past many were stuck in jobs solely for the purpose of keeping health insurance because they would have been denied coverage elsewhere because of pre-existing conditions.

So why is there less enrollment than anticipated? There are two barriers to fuller enrollment that the Forbes article does not acknowledge. The first barrier more critical to less than anticipated enrollment is the reality that 19 states have still not expanded Medicaid, the public insurance program through which it was anticipated many of the newly insured were to become insured. The ASPE Data Point Report shows that expansion states have dropped to lower rates of uninsurance (from 18.2% to 10.1%) compared to non-expansion states (from 23.4% to 16.1%), though it is telling that the non-expansion states had farther to go, indicating perhaps a less friendly environment for employment based opportunities for insurance and a host of other contextual issues that drive health disparities in those states at the start.

The second reason is that most of the states that are relying on the federal government to run their insurance exchanges had less enthusiasm for the law and perhaps created less supportive environments to ensure that all eligible individuals knew of their new insurance options. One cannot blatantly ignore the political realities that have created fear around the law and discouraged eligible families to consider their options. It is therefore understandable that initial anticipated goals have not yet been reached and it remains an uphill battle in many states to get to expected enrollment numbers.

Agreed that it would have been best not to have overestimated the potential of the ACA to decrease the number of uninsured, especially in such a hostile political environment. Still, you can decide if a drop from over 20% to under 13% uninsured makes the ACA a success or a failure. And then we can determine what needs to be done to make sure that more Americans can gain insurance.

How the health care law is making a difference for the people of Kansas

A report issued by the Department of Health and Human Services details how the people of Kansas are faring after the implementation of the Affordable Care Act (ACA/Obamacare).  The full report can be found here:  http://www.hhs.gov/healthcare/facts/bystate/ks.html

It is written by the administration so the tone is favorable.  The report has a section that details who is now insured through the Kansas Health Insurance Marketplace (the Kansas Exchange).  Over 57,000 selected plans in that marketplace.  And, as for the national average, almost 80% of 57,000 are receiving financial assistance paying for the premiums.

States have a choice as to whether or not to expand their Medicaid programs.  Kansas is one of 24 states that have chosen not to expand at this time.  Still, because of heightened interest in health insurance, over 28,000 Kansans have been newly enrolled in the Kansas Medicaid program, KanCare.  If Kansas had expanded there would be another 100,000 eligible.

The report goes on to give additional detail about new coverage benefits and how many Kansans are affected.  It also acknowledges that in Kansas, Medicare beneficiaries have save over $100 million on prescription drugs because of new cost sharing in that program.




Where are we now that open enrollment has closed?

It’s been a busy few months as we reached the ACA enrollment deadline.  There are lots of reports of how many are actually enrolled (about 8 million with the latest report).  The White House also announced that 35% of those who signed up for coverage were under 35. Twenty-eight percent are between the ages of 18 and 34, falling just shy of the administration’s 40% target. This demographic is needed to keep premium levels down, and to offset the costs of insuring older, and likely sicker, enrollees.
As importantly there have been several recent surveys showing that the rates of the uninsured are dropping.  For a good summary of those reports and explanations of what they mean see http://www.californiahealthline.org/articles/2014/4/17/surveys-highlight-acas-effect-on-us-uninsured-rate
Because some consumers will be eligible for special enrollment periods and KanCare enrollment is year-round, we expect to see the insured rate increase over time. We will be sure to pass along the most recent data on the number of Kansas’s successful enrollments as they are made available – so stay tuned!
There are important questions to be answered and I suspect we will see research trying to answer these in the coming months:
•    Who is still uninsured?
–    What are their options?
–    What will states do re Medicaid expansion?
•    Who is now uninsured who was previously insured?
–    Some very high cost counties, region and age
–    What happened with cancellations? Who was affected? Is new option better?
–    Did mandate work consistently across populations?
•    Is insurance affordable?  In whose terms? And through time (are premiums rising more or less than before?)
•    Has more insurance led to better health outcomes for individuals?  How has it affected community vitality?