Not News, But History - A New Look at Medicaid Expansion

                لمشاهدة الفيديو كامل HD 
              والتحميل مجانا

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Now that 2014 and Obamacare are both here, there will be plenty of stories about Affordable Care Act implementation.  Some will be newsworthy; but others will just be history. 

Last week, we got our first history story characterized as exploding news.

The Washington Post reported on a newly-released Harvard study that analyzed the impact of the 2008 Oregon Medicaid expansion on hospital emergency department visits.  The study found that there was a 40 percent increase in the number of emergency department visits made by the new Medicaid enrollees.

For the Post article, an MIT health economist (I guess no Harvard ones were available!) commented  that he viewed it “as part of a broader set of evidence that covering people with health insurance doesn’t save money,” something he went on to characterize as a “misleading motivator for the Affordable Care Act.”

And Forbes went farther, claiming the study results are “undermining [the] central rationale” for ACA.

But the Oregon expansion increase wasn’t really news by itself, and it tells us nothing about the Affordable Care Act, either.

There are three reasons for this.

The first reason is that Medicaid recipients, as a group, have always been the most frequent users of emergency department care. 

I learned about this up close when I was involved in a community health project in Austin, TX, more than a decade ago. 

We compared the use of emergency departments for non-emergent reasons by privately insured, Medicaid-insured, and uninsured residents.  About half the visits made by privately insured or uninsured people were for non-emergent reasons.  But 60 percent of those made by Medicaid recipients were for non-emergencies. 

The same thing was true when that analysis was repeated in other hospitals in other parts of the country.

So the new study simply confirms what we have known to be the case for years.  Medicaid recipients use hospital emergency departments for non-emergent care more frequently than those who are not on Medicaid.

The second reason is that we also know why Medicaid recipients have historically gone to emergency departments for their non-emergency care. 

It isn’t that emergency rooms are more conveniently located than private doctors and walk-in clinics.  Or that some hospitals now use billboards, texting, or other mass media to advertise shorter emergency department waiting times.

It is simply because – unlike many private primary care providers – hospitals have historically been paid enough to take part in the Medicaid system. 

But there are new realities under the Affordable Care Act.  More federally-qualified health centers are being approved, and other private primary care providers are seeing increased rates – rates comparable to Medicare – for treating Medicaid patients.

While change won’t happen overnight, this means that over time more private providers will be signing up for Medicaid in the expanded Medicaid program, and more Medicaid patients will be choosing them over hospital emergency departments because they can.

And that makes the results of an expansion program that took place six years ago an interesting history lesson, but as poor a predictor of what will happen in the future under a different set of rules as historical stock market performance is of future returns.

The third reason is that cost-savings was not a “misleading motivator” for supporting the Affordable Care Act.

Despite the suggestion of the MIT economist and the Forbes headliner, it wasn’t actually a reason at all.  When the Act was debated in 2009 and 2010, it was clear to all that it was essentially cost-neutral. 

Both the CBO and the Administration projected that we were going to be spending about the same amount on health care overall for the next ten years whether or not we passed the law.  But the law would distribute the costs and savings differently.

Medicare and Medicaid would take on a slightly greater share of costs.  Out-of-pocket costs not covered by public or private insurance would go down (especially for those with chronic diseases and conditions who could not afford insurance in the past).  And private insurance would continue to pay just about one-third of the nation’s health care bill.

While not everyone in the media may have known this at the time, all the people voting on the law did.

That’s not news.  That’s history.

Just like the new Harvard study.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

The Best States for Your Health

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.  

A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health. 

Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades.

We would all like a more effective health and health care system.  But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a new ranking of the states that reflects which states invest most effectively in our health and health care. 

It was created by combining four existing rankings and three new ones.  It includes mental health as well as health, the work of other health professionals in addition to doctors, and availability of community care as well as quality institutional care.  It ultimately rates the states based on how good they are at simultaneously:     

• keeping their children and adults healthy; and 
• taking care of their residents when they are sick or have chronic conditions; and 
• providing for both health and health care at a price their residents can afford. 

Taking everything into account, here are the ten best States for Your Health, and why:

1. Massachusetts.  Massachusetts is the only state with five top five finishes among the seven rankings.  It takes good care of its children, invests in wellness and prevention, has many top-rated hospital programs including one of the highest rated mental health facilities in the country, and insures its population well.  Where health and health care are concerned, every state should want to be more like Massachusetts.
2. Connecticut.  Connecticut is near the top in six of the seven rankings.  Its children, working adults, and elders all thrive on a rich set of high-quality prevention and health care services. The only ranking in which it did not excel was one that measured affordability – the high amount its Medicaid program historically spends on hospital and nursing home care. 
3. New Hampshire.  New Hampshire rates as the best state in the nation in three of the individual rankings I combined – the 2011 Kids Count child health and well-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per 100,000, and the percentage of people who are privately insured.
4. Vermont.   Vermont is number one in the Healthy State rankings and in keeping its Medicaid hospital and nursing home costs under control.  It has figured out that the best way to control Medicaid spending is to keep its population healthy.
5. Utah.  Utah proves that good health is a conservative value.  It takes good care of its children, promotes healthy lifestyles among its residents, and is home to a high percentage of residents with private employer-based insurance – a key measure of affordability.
6. Minnesota.  Strong in the prevention and public health rankings, Minnesota is also home to a top hospital.  It gives its residents access to quality public health and quality health care at the same time.
7. Washington.  Washington cracked the top ten in only one individual ranking, so it may be a surprise that it is ranked so high when they are all combined.  But it does just about everything well compared to other states, and isn’t close to the bottom in any category. 
8. Hawaii.  Hawaii scores high in prevention and keeps Medicaid institutional spending under control.  It doesn’t have any of the top rated hospital programs.  If it did, it would rank even higher.
9. New Jersey.  New Jersey does especially well by its children and its elders, and is in the top ten in three individual categories.  But it is an expensive state for Medicaid recipients to get sick in, and a lot of that money goes to hospitals and nursing homes. 
10. Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individual rankings.  If its residents were able to spend relatively more of their Medicare dollars on community services and less on institutional ones, it would move up.

There are two states that topped individual rankings that didn’t make the top ten.  California, according to US News and World Report the best state in the nation to find high quality hospital programs, tied for 15^th.  Florida, first in per capital Medicare spending on community services, finished 30^th. 

To see the full ranking of all the states, click here.

Next week:  More about why Florida finished where it did, and a closer look at the ten states that finished near the bottom.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Note: Here are the rankings I used, the reasons I used each of them, and a link to the 

original data: 

• the 2011 Healthy State Rankings and the 2011 Annie E. Casey Foundation Kids Count state rankings – to measure the effectiveness of public health and overall prevention (including mental illness prevention) activities; 
• the Kaiser Family Foundation (KFF) State Health Facts ranking of the percentage of people with private employer-based insurance – to measure health care access and affordability for workers and families; 
• the KFF State Health Facts ranking of the number of nurse practitioners per 100,000 residents – to measure support for non-physician providers and high quality primary care;
• To measure quality of care and medical professional development, I calculated and ranked the states by the number of times a hospital in a state was included in the 2011 U.S. News and World Report rankings of best hospitals in the country across specialties, including mental health and overall rankings of children’s hospitals (33 states had at least one hospital mention);
• To measure the availability of community-based services for elders, I used the most recently available data from the Centers for Medicare and Medicaid Services reporting per capita state spending in each state on Medicare minus hospital and nursing homespending;
• To measure the effectiveness of state intervention to keep people with disabilities in their homes and out of institutions and as a measure of affordability, I used CMS data to calculate per capita state spending on Medicaid hospital and nursing home care as a negative measure.

Because prevention and health care each account for approximately 50% of the gains in life expectancy over the last century, I gave the two prevention-oriented rankings – the Healthy State and Kids Count rankings  – a combined weight equal to that of the other five.