In 2014, the Gap Will Widen between the Health and Mental Health "Haves" and "Have Nots"

Let’s open 2014 with four health policy predictions.  Here are the first three:

• Obamacare enrollments will top 5 million.
• Uninsured rates will come down.
• Health inflation will tick up.

Here’s why you can count on these.  

First, 1.1 million people have already enrolled in Obamacare.  The Administration hopes for 7 million by March.  That may be optimistic, but there will be another burst of enrollments in a couple of months.  And there will be another open enrollment period toward the end of the year. 

So at least 5 million enrollments seems reasonable.  And here is a bonus prediction.  If that many sign up, the politics of Obamacare in the half of the states that have embraced it will probably shift during the 2014 election cycle.  Their people will, too.

Second, the number of people who are uninsured will go down.  A 1 or 2 percent decline will be attributable to Obamacare.  The improving economy will also help.  And this means that the numbers will be better even in the states that did not embrace Obamacare.

Third, because more people will be insured and getting care, health inflation will go up again.  Both the Congressional Budget Office and the Administration have been predicting this for 2014 ever since the passage of Obamacare. 

In fact, if it doesn’t happen, this will probably be the health policy news story of the year.

But the fourth prediction may be most significant of all.  The gap will widen between the states with better health and mental health care and those with worse. 

And this has everything to do with Medicaid money.

As of December, the states were literally divided down the middle between those that decided to expand Medicaid in 2014 and those that did not.  If you compare the 26 states (including the District of Columbia) that decided to expand Medicaid to the 25 states that did not, the expanding states already have a decided advantage in supporting health and mental health care.

And with hundreds of billions more dollars flowing into those states over the next few years, that gap will probably widen.

Consider how these Medicaid dollars could widen the gap in just two areas – the number of nationally-ranked hospital specialty programs in a state and mental health spending. 

First, think about the high-quality hospital specialty services we all want and sometimes need.  Hospitals rely on Medicaid dollars for a significant portion of their revenue.

Medicaid-expanding states already have significantly more nationally-ranked hospitals and specialty programs, according to the U.S. News and World Report 2013-2014 rankings, than states that do not.

Seven of the ten states with the greatest numbers of nationally-ranked specialty programs decided to expand Medicaid.  And consider the advantage already enjoyed by California (ranked #1 in number of nationally-ranked specialty programs) and New York (#3) over the two most-populated states that decided not to expand Medicaid – Texas (#6 in number of nationally-ranked specialty programs) and Florida (#11).

California and New York, with 678 hospitals between them, are home to a total of 28 hospitals with at least one nationally-ranked specialty, with a total of 154 nationally-ranked specialties overall.

Texas and Florida, with 895 hospitals between them, are home to a total of 16 hospitals with at least one nationally-ranked specialty, with a total of 70 nationally-ranked specialties overall.

Texas and Florida are leaving as much as $100 billion on the table over the next ten years, much of which would have ended up on hospitals’ bottom lines.

The same point can be made regarding funding for care for people with mental illnesses – on whose behalf many of those Medicaid expansion dollars will be spent. 

The 26 states expanding Medicaid already spend much more on mental health services than those are not.  And the disparity is striking.  According to the Kaiser Family Foundation, the average state spends $120 per capita on mental health agency programs. 

But the states expanding Medicaid spend $139, on average, compared to $116 by states that refused.

And even these spending numbers look artificially close because of high per capita mental health spending in states like Alaska and Maine, which have small populations.  When population size is taken into consideration, as is clear from the pie chart above, the expanding states account for nearly twice as much of the nation’s per capita mental health spending as do the non-expanding states. 

And that gap – like the gap between the “haves” and “have nots” – will only widen in 2014.

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, 2013

After a year in second place, Massachusetts is once again the best state for your health in the 2013 Our Health Policy Matters rankings.

In first place in 2011, Massachusetts dropped to second last year behind Connecticut.  It edged out Connecticut this year based on the rankings of all fifty states in a combination of seven national source rankings and/or spending categories.

Here are the top ten states, with the change from last year’s ranking in parentheses.

1. Massachusetts (+1).  Among the seven components of the rankings, Massachusetts was only 4^th in the Healthy State rankings, and 11^th in the Kids Count health rankings.  But it earns its top rank overall because of consistently high placements in five other health care rankings.

2. Connecticut (-1).  Last year’s winner, Connecticut ranks 2^ndoverall in the Kids Count health rankings and in the percentage of residents with employer-based private insurance.  But it is only in the middle of the pack (20^th) in total number of high-quality hospital programs.

3. New York (+3). Never highly ranked in the healthy state rankings (18^th this year), New York has jumped from 19^thto 3^rd in two years on the strength of its hospitals, and good access to care for both younger and older residents.

4. Vermont (+3). Vermont tops the healthy state rankings and is 4^th in the Kids Count health rankings.  With an earlier investment in universal health care for its residents offsetting its lack of high-quality hospital programs, it may go higher in the future.

5. Maine. (+3). Maine tops three individual categories – the Kids Count health rankings, Medicaid access, and primary care access – accounting for its three-place gain this year.

6. Minnesota (-2). Minnesota scores highly in the Healthy State rankings, and also has high-quality hospital programs and a highly-insured population.Wisconsin (+6).  

7. Wisconsin owes its improvement in the ranking to healthy kids (3^rd) and solid performances in most other categories.  But it lags a bit in the Healthy State and primary care access rankings.

8. Utah (0). Utah scores well in the Healthy State rankings (7^th), but less well in the Kids Count health rankings (14^th).  It also has a high percentage of its population covered by employer-based insurance.

9. Washington (+7). Like Wisconsin, Washington made a big move into the top ten this year on the strength of a solid Kids Count health ranking (6^th).

10. Maryland (+2).  Maryland is in the top ten in the Kids Count ranking and in the percentage of its population with employer-based insurance.

In individual categories, Maine had the most first place rankings – the Kids Count health ranking, the primary care access ranking, and a tie for first in Medicaid access. California (19^th overall, up 3 places from last year) placed first in the number of high quality hospital programs and tied for first in the Medicaid access rankings.  Vermont topped the Healthy State rankings and tied for first in Medicaid access.  New Hampshire (11^th overall, after a 4^th place showing last year) placed first in employer-based health insurance. 

And Florida (34^th this year, down one place from last year) was first in community Medicare spending.

These rankings are the last before some significant Obamacare changes go into effect next year. For example, Vermont (ranked 4^th), Maine (5^th), Wisconsin (7^th), and Rhode Island (12^th) have all announced plans to cut their Medicaid rolls to encourage people to enroll in the exchanges, according to an article this week in Kaiser Health News.   Next year’s rankings may be adjusted to take into account insurance exchange enrollments in all the states.

Washington (9^th), Delaware (18^th), and Oklahoma (43^rd) were the biggest gainers this year.  They all gained seven spots in the rankings. New Jersey (13^th) experienced the biggest drop – 10 places. Virginia (23^rd) lost nine places, and Pennsylvania (16^th) and South Carolina (48^th) each lost eight.

Next week: the ten worst states for your health.

To see the full rankings of all fifty states, click here.

How These Rankings Are Developed:

OHPM combines seven rankings of the states to create this Top Ten.

Two of the rankings among the most highly-regarded public health or prevention-focused rankings – the United Health Foundation/APHA/Partnership for Prevention America’s Health Rankings and the Annie E. Casey Kids Count state health rankings.  The most recent America’s Health (Healthy State) Rankings were published in December 2012, and the most recent Kids Count health rankings were released in June 2013.

Because prevention and public health account for 50 percent of the gains in life expectancy over the last century, these two rankings account for 50 percent of the weight in the OHPM rankings.

The other five components of the ranking account for the other 50 percent, and are related to health care access and quality.  This year, they include the number of nurse practitioners and physician assistants per capita in the state (as a measure of the strength of the state’s primary care system), the percentage of state residents with employer-based private insurance and with access to Medicaid (as a measure of the availability of third-party payments for health services in general for the under 65 population), community-based Medicare spending (as a measure of the availability of elder health services), and, from the 2013 US New and World Report Hospital Rankings, the total number of high quality hospital specialty programs in the state (as a measure of the availability of specialty care for all chronic diseases and conditions).

To see the full rankings of all fifty states, click here.

Source links:

http://www.americashealthrankings.org/mediacenter/mediacenter2.aspx

http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3

http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=7248

http://kff.org/medicaid/state-indicator/medicaid-enrollment-as-a-of-pop-fy09/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

http://health.usnews.com/best-hospitals/area

http://data.bls.gov/oes/search.jsp?data_tool=OES

http://samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

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

The Worst States for Your Health

Some states do a much worse job than others of keeping their residents healthy and providing for high-quality, affordable health care when their residents need it.  People usually live shorter, less healthy lives in these states than they might if they lived elsewhere.

In my last column, I described a new States for Your Health ranking, and examined the states that finished near the top.

This week, I want to look first at why Florida, ranked first in one of the seven indicators – per capita Medicare spending on non-institution-based services – only finished 30^thoverall.

Florida’s doesn’t invest enough in public health and prevention.  It is 36^th among the states in the 2011 Kids Count rankings, and 37^th in the 2011 Healthy State rankings.  Children in poor environments for their health are more likely to develop both physical and mental illnesses as they age.  Obesity, cancers, heart diseases, and mental illnesses are all expensive, and can cut decades from life expectancy.  

Florida’s care quality rankings are much higher than its prevention rankings.  It is 11^thin the number of times its hospital programs made the U.S. News and World Report national rankings.  These high quality programs are usually found in just a few hospitals in major cities, but this is the case in most states.  It is 16^th in nurse practitioners per 100,000 residents, and 19^th best in keeping Medicaid nursing home and hospital spending under control. 

Florida is, however, is near the bottom (45^thplace) in the percentage of residents with private insurance.  That hurts.

The ten lowest ranked states either score exceptionally low in the prevention or health care rankings, or consistently low across the board: 

50. West Virginia.  The lowest-ranked state isn’t at the bottom in any individual ranking.  It is just near the bottom everywhere – 40^th in the percentage of people with private insurance, 43^rd in the Healthy State rankings, and 44^th in Kids Count.  It broke into the top half in only one ranking, the amount its Medicaid program spends on hospitals and nursing homes.  Even that may not be such a good thing.  While low Medicaid spending on institutions was considered positive in this ranking, it is also an indicator of low spending on health care in general.

49.  Louisiana. Louisiana finished next-to-last in both the Healthy State and Kids Count rankings.  That’s why it’s 49^th here, too.  On the other hand, it was 2^ndin per capita community Medicare spending, and has some quality hospital programs.  It clearly has assets on which to build.

48.  Mississippi.  Mississippi is last in the Kids Count and Healthy State rankings, and next to last in percentage of people with private insurance.  However, it is in the top ten in community-based Medicare spending and in the number of nurse practitioners per 100,000.  Both could contribute to a healthier state in the future.

47.  Oklahoma. Oklahoma is in the bottom ten in nurse practitioners, Kids Count, and Healthy State rankings.  It is also one of 18 states with no highly ranked hospital programs.

45t. Arkansas.  Arkansas’s profile looks similar to some of the others at the bottom.  It has low prevention ratings that bring down its overall ranking, but it is near the top in number of nurse practitioners and limiting Medicaid hospital and nursing home spending. 

45t. Kentucky.  Kentucky isn’t near to the bottom in any single indicator.  It is just consistently weak across the board.

44. New Mexico.  New Mexico is in last place in the percentage of people privately insured.

43. Nevada.  Nevada is in last place in the number of nurse practitioners.

42. Alabama.  Alabama ranks low in prevention and primary care rankings.

41. Montana.  Montana is as high as 25^th in the Healthy State rankings, but it lags in Kids Count and all of the health care rankings.

Two states finished last in individual rankings but did not make the bottom ten.  South Dakota was at the bottom in community-based Medicare spending per capita, but ranked 29^thoverall.  New Jersey spent the most from its Medicaid program on hospital and nursing home care, but still finished 9^th overall.

To see the complete rankings, click here.

If there is a bottom line, it is this.  Despite our discouragement with our public health and health care systems in general, people in nearly every state have at least something for which to be thankful.  And there will be better days ahead for all of us if policy leaders understand that we want them to do more for our health, not less.

Happy Thanksgiving!

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.